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Dr. F. M. Farnsworth 

B uckhannon, ¥. Va. 



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Anesthesia in the Oral Cavity 
for the Different Branches of 

logical Study of Infectious Foci 
in the Mouth and Their Rela- 
tion to Somatic Diseases. 









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strictly reserved. 

Copyrighted at the Registry of Copyrights, Washington, D.C. 

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ROENTGENOLOGY has become a most important means of diag- 
nosis and a great aid in the treatment of diseases of the oral cavity. 

For many conditions the Roentgenogram is only used to ascertain 
the exact nature of the lesion which has already been diagnosed by other 
methods, but for chronic diseases which occur without giving any symp- 
toms, the Roentgen method is sometimes the only way by which the lesion 
can be discovered. In searching for the cause of nerve irritation or for 
foci of infection, negative findings are often as valuable as positive ones 
in establishing the presence of and eliminating oral diseases as causative 

No dentist who has the welfare of his patients at heart can practise 
to-day without the aid of this important method of examination. The 
research workers and pioneers of the profession have found the Roentgen- 
ogram a valuable aid in checking up the results of new treatments in order 
to prove or disprove the advantage of the new procedure. 

A Roentgen machine is a great asset to the office equipment of a dentist, 
but if he would rather rely on a specialist for taking the Roentgenogram 
he has the advantage of being able to consult a man who has had wide 
experience and special training in this branch of dentistry. In many 
cities Roentgenology has been made use of as a trade, and laboratories 
have been established by laymen who not only take pictures, but furnish 
elaborate reports. They are not to blame, however, nor can the law 
successfully stop them. The fault lies with the men of the profession who 
patronize them. Such practitioners lower the standard of this important 
specialty and of the dental profession in general, to say nothing of the 
danger of exposing patients to ignorant diagnostitians and infections which 
may be carried from one mouth to another. 

The Roentgenologist should have a special knowledge of the anatomy, 
histology and pathology of the parts he is examining, as well as a famili- 
arity with all the problems of dentistry and the various supplementary 


methods of diagnosis. It is only such knowledge which can enable the 
Roentgenologist to make a correct diagnosis from a Roentgen picture, 
which does not record disease, but only variations in the radiability of 
the various organs, structures and tissues. 

The author's aim is to base the Roentgenographic study of the mouth 
upon a broad knowledge of anatomy, histology and pathology and, in the 
first part, to give the student, as well as the practitioner, a chance to 
compare photographs showing the outside and inner make-up of the jaws 
with the Roentgen picture. In the following parts the various diseases 
affecting the teeth and jaws are taken up according to their pathological 
classification. Whenever possible, there was a photograph added to show 
how the tissues were affected by the disease, while a large number of 
Roentgenograms were put in to illustrate practical cases. With most of 
the pictures has been given a history of the case, a conclusion from the 
Roentgen picture and a report of operative findings, the result of the 
operation having been added sometimes with the intention of not only 
showing pictures, but of giving the reader a most intimate knowledge of 
the case. In the last part, the use of Roentgen pictures as an aid in treat- 
ment is taken up and the illustrations have been chosen with the idea of 
making the chapter a practical help. 

The majority of the photographs and Roentgen pictures are original, 
the cases either having been referred for Roentgen diagnosis or surgical 
treatment to the author, who wishes, however, to acknowledge here his 
gratitude to all of his professional friends who have contributed indi- 
rectly to this book by referring to him the patients whose Roentgenograms 
have been used. A number of special contributions have been gratefully 
received from Dr. A. W. George, Dr. Ralph Leonard, Dr. L. B. Morison 
and others, to whom the author particularly extends his thanks for their 
interest in this volume. All special contributions have been acknowledged 
under the description of the case. 

Kurt H. Thoma, D. M. D. 

43 Bay State Road, 

Boston, Massachusetts, 
June 20, 1917. 




Roentgen Nomenclature ii 

Interpretation of Roentgenograms 12 

extraoral roentgen method i4 

Intraoral Roentgen Method 14 


1. The De\'elopment of the Teeth 21 

Calcification of the Temporar}- Teeth 22 

Eruption of the Temporarj' Teeth 22 

Decalcification of the Temporan- Teeth 23 

Calcification of the Permanent Teeth 24 

Eruption of the Permanent Teeth 24 

Chronology of Human Dentition 25 

2. The Normal Adlxt Jaws and Teeth 25 

The IMaxilla 26 

The Maxillary Sinuses .- 26 

The ]Mandible 26 

The Mandibular Joint 27 

The Mandibtilar Canal 27 

The Normal Relation of the Teeth to the Jaws 27 

The Teeth in Youth and Old Age 27 


1. Irregular Eruttion of the Teeth 51 

Misplaced Teeth 5^ 

L'nerupted, Impacted Teeth 52 

Partially Erupted, Impacted Teeth 53 

Retention of Temporary Teeth Due to Absence or Impaction of Permanent Ones 53 

Congenital Absence of Temporary and Permanent Teeth 53 

Supernumerous Teeth 53 

2. Diseases of the Hard Tooth Substances 74 

Abrasion 74 

Fractures 74 

Caries 74 

Odontomata 74 

3. Diseases of the Dental Pulp and Their Sequel, Alveolar Abscesses ... 86 

The Size, Shape and Number of Root Canals 86 

Pulp Stones 86 

Inflammatory Processes of the Dental Pulp 86 

.Acute Periodontitis and Acute .\lveolar Abscesses 87 




Chronic Alveolar Abscess 87 

Proliferating Periodontitis and Dental Granuloma 87 

Apical Granuloma 88 

Interradicular Granuloma 88 

Lateral Granuloma 88 

Results of Alveolar Abscesses on the Root Apex 89 

Exostosis of the Root 89 

Necrosis of the Root 89 

4. Diseases of the Marginal Part of the Periodontal Membrane 106 

Marginal Periodontitis or Pus Pockets 106 

Marginal Periodontitis Due to Impaction and Difficult Eruption 106 

Pyorrhea Alveolaris 106 

Abscesses Due to Marginal Periodontitis 107 

5. Diseases of the Jaws 116 

Atrophy i 

Fractures i 

Diffuse Osteomyelitis i 

Ostitis I 

Necrosis i 

Periodontal or Radicular Cysts i 

Multilocular Cysts i 

Follicular or Dentigerous Cysts i 

Tumors i 

Osteoma i 

Osteosarcoma i 

Carcinoma i 

6. Diseases of the Air Sinuses i 

Maxillary Sinusitis 148 

7. Salivary Calculi 154 



1. The Treatment of Root Canals 159 

Prognostic Roentgen Examination before Removing Pulps from Vital Teeth . . 159 
Prognostic Roentgen Examination of Previously Treated Pulps and Pulps which 

are to be Treated i6o 

The Use of the Roentgen Ray as a Guide in Root Canal Cleaning and Filling . 160 

2. Apicoectomy 16 

Prognostic Roentgen Examination 16 

Checking up of the Different Steps 16 

Following up the Heahng Process 16 

3. Prosthetic Dentistry and Orthodontia 16 

Conditions of Roots Used for Prosthetic Abutments 16 

Unerupted Teeth and Broken-off Roots 162 

Orthodontic Treatment of Unerupted or Partially Impacted Teeth 162 

4. Treatment of Fractured Jaws 162 

5. The Healing of the Jaws After Operative Interference 162 

The Removal of Foreign Bodies and Odontoma ta 162 

The Healing of the Jaws after Bone Operations 163 





Oral Lesions as the Primary Cause of Systemic Diseases 199 

Secondary Lesions 199 

Discharge of Pus into the Mouth 199 

Absorption through the Lymphatic Channels 199 

Absorption through the Blood Channels 200 

Oral Lesions as Secondary Factors 200 

Referred Nervous Irritation 201 

Examination of the Oral Cavity by the Dentist 201 

Examination of the Oral Cavity by the Physician 202 


IT is not in the scope of this book to describe Roentgenographic appara- 
tus and technic^ue. These details can be acquired from books written 
on this subject and, for dentists, there is none better than Raper's " Ele- 
mentary and Dental Radiography." To obtain clinical information from 
Roentgenograms and to teach the general practitioner, as well as the 
student, to depend on his own eyes in interpreting the conditions pre- 
sented to him, it is important to understand first the basic principles 
involved in applying the Roentgen ray and to have an exact knowledge 
of what is meant by the special terms used in this science. 

Roentgen Nomenclature, There are a great many Roentgen terms 
in use and there has, so far, been no standardization in dental literature- 
In this book, the terms employed are those which have been adopted by 
the American Roentgen Ray Society, October i, 1913 and accepted 
by the Journal of the American Medical Association, The Committee 
on Nomenclature of the American Institute of Dental Teachers also 
recommends their use. 

Roentgen Ray. A ray discovered and described by Wilhelm Conrad 

Roentgenology, The study and practice of the Roentgen ray, as 
applied to medical science. 

Roentgenologist. One skilled in Roentgenology. 

Roentgenogram. A shadow picture produced by the Roentgen ray 
on a sensitive plate or film. 

Roentgenograph. (Verb) To make a Roentgenogram. 

Roentgenography. The art of making Roentgenograms. 

Roentgen Diagnosis. A diagnosis made by means of Roentgenograms. 

In addition to these terms the following words have been made use of, 
the three latter having been supplied by Dr. Ottolengui to meet a long 
felt need adequately to express certain properties: 


Radiability. The property of an object to transmit the Roentgen ray. 

Radioparent. 1 ^£c . T_ . , -^ 

_, 1- Ottering no barrier to the Roentgen ray. 

Radioparency. J fe J 

Radiolucent. 1 ^^ . ,. , . , -^ 

Radiolucency. I ^^^"^S shght resistance to the Roentgen ray. 

Radiopaque. ] ^ . , ^ 

-r, Impervious to the Roentgen ray.^ 

Radiopacity. J ^ & J 

Interpretation of Roentgenograms. The Roentgen picture records 
upon a photographic plate or film the various obstructions of the tissues 
placed in the path of the ray. The nearer the object is brought to the 
plate, the more precise and less distorted is the picture. The radiability 
of different objects varies. The soft tissues are very radiolucent, trans- 
mitting the ray easily, but not as weh as air, while bone, which contains 
little organic matter, is radiopaque. A tooth is more radiopaque and 
enamel still more so, on account of its high percentage of calcium salts. 
Cavities in the bone, such as the maxiUary sinuses, are highly radiolucent 
when in healthy condition and produce a dark image on the plate. 

The first three illustrations depict such changes in the radiability. 
Figure i shows part of the mandible. Note that the second molar is a 
perfectly normal tooth. If part of the tooth substance is lost the radia- 
bility is increased, as happens when decay causes a cavity. This is illus- 
trated in Figure 2, showing a buccal cavity in the second molar. Metal 
placed in this cavity obstructs the rays and its radiopaque property leaves 
the surface of the film light (see Figure 3). 

Pathological Conditions. The degree to which pathologic conditions 
can be recognized in the Roentgenogram depends upon what can be demon- 
strated upon the Roentgen plate. It gives us a picture in the anatomic 
pathological sense, since the finer pathologic conditions shown by a 
microscope will not produce an effect which can be differentiated by the 
eye. When studying pathological conditions by means of the Roentgen 
ray, it should also be kept in mind that a Roentgenogram does not show 
disease, but only the comparative value of the radiability of the tissues. 

The etiological factor, the duration of the disease and the fact whether 
a lesion is acute or chronic cannot be found out by the Roentgen method. 
We may find radiolucent areas which we associate from experience with 
necrosis, but the Roentgenogram gives no information as to whether they 

1 Editorial: Items oj Interest, Feb. 1917, Page 141. 


are syphilitic or tubercular, of acute type or long standing. Disease may 
affect the radiability in various ways. Fracture of a bone will leave 
a radiopaque area between the fragments. Accumulation of pus in the 
cancellous part of the jaws without involvment of the bone will decrease 
the radiability; if it occurs between the bone and the periosteum it may 
not make enough difference to leave a record, while the destruction of 
bone, due to inflammatory processes, will greatly increase the radiability 
and show as a dark area on the plate. 

When examining Roentgenograms one should always compare the part 
under observation with the corresponding part of the individual who is 
being examined. This is often of great value, especially if there is only 
a slight deviation from the normal, as, for instance, in the case of the 
sinuses of the face. It is the comparative value of the radiability of 
the normal sinus on one side and the suspected one on the other side by 
which the Roentgen diagnosis is made. 

The location of the suspected trouble is first ascertained and then 
one should determine the exact position of the object and its relation to 
the surrounding parts. This is done by means of two or more Roentgen- 
ograms taken from various angles, or by means of a stereoscopic Roentgen 

The size and shape of the part should be noticed, in order to recognize 
any departure from the normal, such as increased size or irregularities. 
The age of the patient ought to be considered also and the condition com- 
pared with that of the normal part of the same age. It is normal to find 
an unerupted cuspid in a child ten years old, but at the age of forty, it 
would be an abnormal condition. 

Misconceptions may arise from a distortion of the angle at which the 
picture is taken, from faulty technique, the interposing of other parts, or 
lack of knowledge and training in anatomy and pathology; also from 
incorrect interpretation of what the eye is actually seeing. Part of the 
maxillary sinus is frequently superimposed at the ends of the roots of the 
upper molars and bicuspids and is liable to be interpreted as a large 
pathological cavity. The mental foramen is often projected to one side 
and, especially on extraoral Roentgen pictures, may be seen as a dark 
area at or near the apex of the lower second bicuspid. If the tooth is 
devitalized, several Roentgenograms are needed to make sure of the 
finding. However, one can nearly always trace the mandibular canal 


and if it leads to the dark area we have to do with the foramen. In 
pictures of the upper incisors the incisive foramen also causes confusion 
at times. While it is generally a well-defined triangular area in the median 
line and above the incisors, it may occasionally be projected towards 
one side and if it happens to be superimposed over the apex of one of the 
centrals, it might be misinterpreted. When taking intraoral pictures 
of the last molars in the upper jaw we often include the projection of the 
zygomatic process of the maxilla, which at this angle decreases the radiabil- 
ity and part of the coronoid process of the ramus is frequently inter- 
posed when the picture is taken from a more posterior angle. This, at 
times, gives the appearance of a decayed root (see Figures 4 and 5). 
A proper allowance must also be made for distortions of various parts, 
due to bending of the film. Many incorrect readings can be avoided by 
taking two or three exposures from varying angles and it is also a great 
advantage to develop the pictures while the patient is waiting, so that in 
case of doubt the pictures may be repeated. 

Extraoral Roentgen Method. The large extraoral plates are very 
useful for giving an entire survey of the region involved. Without them 
malposed teeth, large cysts, affections of the ramus and diseases of the 
maxillary sinuses might often escape notice, as such conditions cannot 
be included in the small films which are used inside the mouth. 

Intraoral Roentgen Method. The intraoral method, however, is 
the one usually chosen to diagnose the conditions closely associated with 
the alveolar process or the teeth when in normal position. Such pictures 
are always much more distinct and show detail with more accuracy than 
the extraoral plates because they can be brought closer to the object. 
There is also less danger of distortion and superimposition of shadows. 
However, if the intraoral picture leaves any doubt, or shows a condition 
only in part, one should make it a rule to take an extraoral picture at once. 

Roentgen Negatives and Roentgen Prints. The Roentgen negative 
is the picture that is produced either on a sensitive plate or film. All ra- 
diolucent parts of the object appear as dark areas while radioparent parts 
show light. Of these Roentgenograms prints may be made by any of the 
methods used in photography. These Roentgen prints show a reversed 
picture, radiolucent parts appear light while the radiopaque objects show 
in dark shades. 

All Roentgenologists use the negative Roentgen picture to make their 


diagnosis from. If duplicates are wanted to keep as records, two plates 
or two films, one placed over the other, are used and exposed simulta- 
neously. The small intraoral films are put up in pairs by the manufacturers 
so that one can be kept as record while the other may be sent with the 
Roentgen diagnosis. 

For reproducing Roentgenograms for publication or lantern slides, 
prints have been used by most of the authors in the past. This, how- 
ever, tends to confuse men who are not very familiar with the reading of 
Roentgenograms. It further has the disadvantage that it renders more 
difficult comparison of the author's Roentgen results with one's own. For 
teaching purposes, however, and as illustrations in textbooks, Roentgen 
prints are as good as worthless because the)" fall short of their purpose. 
The principle aim of the illustrations in a textbook of Roentgenology 
should be to famiharize the student with the appearance of the various 
tissues in health and disease as pictured in a Roentgenogram not as 
printed occasionally in a magazine, but as used daily for clinical purposes. 


Roentgenogram of Normal Teeth 

Figure i. 

The second molar, like the others, is a perfectly healthy tooth. The 
crown, being covered by enamel, is radiopaque and shows hght in the 

Roentgenogram Showing a Radiolucent Area 

Figure 2. 

A cavity on the buccal side of the second molar increases the radi- 
ability and shows darker than the rest of the crown. 

Roentgenogram Showing a Radiopaque Area 

Figure 3. 

A metal filling placed in the cavity decreases the radiability and, there- 
fore, shows as a light area in the Roentgen negative. 



Figure i. 

Figure 3. 


Roentgenology of Conditions Liable to Misinterpretation 

Figure 4. 
Patient: Mr. W. 

Roentgen Examination: Shows part of the coronoid process of the 
ramus in the lower left-hand corner. 

Figure 5. 

Patient: Mrs. W. 

Roentgen Examination: Part of the coronoid process is seen at the 
side of the picture and might be taken for the roots of a wisdom tooth 
with decayed crown. 

Figure 6. 

Patient: Miss H. 

Roentgen Examination: Shows large radiolucent area in lower jaw 
around the apex of the first bicuspid. The second bicuspid is a devitalized 
tooth with root canal filling and shows a slight radiolucent area immediately 
beneath its root. A little further down is a well defined radiolucent area 
lying in the path of the mandibular canal. It is a picture of the mental 



Figure 4. Figure 5. 

■mr' ^^^ 

Figure 6. 

dental school 



THE Roentgenologist should have a thorough and detailed knowledge 
of the conditions which represent living normal anatomy at different 
periods of its development and should also be famiHar with the patho- 
logic conditions representing the various diseases as they appear post 
mortem. The appearance of Roentgenograms of the normal anatomical 
conditions of the oral cavity should, therefore, be studied first and in 
Roentgenology it is not only necessary to be familiar with the external 
anatomy of the part to be examined, but also with the interior structure, 
because the Roentgen picture shows not only the outline, shape and prom- 
inences of the object externally, but gives us also detail of its internal or 
general structure. 

When studying Roentgenograms, it should be borne in mind that the 
various tissues change during life and that what would be normal for one 
period of development would be abnormal for another. Therefore, 
a knowledge of the different stages of development of the teeth and jaws 
should first be obtained. 

1. The Development of the Teeth 
Preparation for the development of the teeth takes place as early as 
the middle of the second month of fetal life and prior to the formation of 
the bony structures which finally surround and give support to them. 
Following the line of the future alveolar ridge, the tooth band is formed 
in each jaw. It is continuous from one end to the other. Soon each band 
throws out ten little buds, which develop into the enamel organs of the 
twenty deciduous teeth. While the enamel organ is developing, a change 
takes place in the connective tissue of the primitive jaw; the cells crowd 
into its concavity and become more highly specialized, forming the 
dentine organ. The two are surrounded by the dental follicle, which is 
formed from the base of the dentine organ. These three parts make up 
the tooth germ and develop highly specialized cells, which produce the 


various parts of a tooth. The enamel organ gives formation to the amelo- 
blasts which form the enamel. The dentine organ deposits dentine at its 
periphery by means of odontoblasts, while the inner part remains as the 
dental pulp. The inner part of the dental follicle, at an advanced period, 
assists in the formation of the cementum by means of cementoblasts, 
while its remaining outer part finally evolves into the alveolo-dental 
membrane. The permanent teeth are formed in similar manner. Before 
the epithelial cord is broken, a bud is given off from the neck of the enamel 
organ, which develops into the enamel organ of the corresponding per- 
manent tooth. From the enamel organs of the incisors and cuspids 
arise the buds of the permanent incisors and cuspids, and from the 
enamel organs of the temporary molars develop the buds of the bicus- 
pids. The first permanent molar originates from a bud given off from the 
posterior extremity of the tooth-band, while the buds of the second and 
third molars emanate from the outer layer of the enamel organ of the 
first and second molars respectively. 

Calcification of the Temporary Teeth. Calcification starts about the 
fourth month of fetal life. The future cutting edges of the incisors and 
the cusps of the back teeth are the first affected. At the time of birth 
the crowns of the incisors are completely calcified and those of the molars 
almost so. Calcification of the temporary teeth is completed at the end 
of the second year when the roots are fully formed and the apical foramina 
established. The diagram shown in Figure 7 gives an idea of how far the 
temporary teeth have become calcified at a given age. 

Eruption of the Temporary Teeth. Bone formation of the jaws 
starts about the middle of the second month of fetal Hfe. Several centers 

Figure 7. 

22■moT^tKs after birtK. 
I 8 Tnonths after birtK. 

iZmonths After birlh 

foTnotiths after birtk. 

30tKweek embTyo. 
IQtKweek embryo.. 
I7th.week emb 

Progress of Calcification of the Temporary Teeth at different Periocis. 


of ossification appear and these soon unite so that the contour of the 
primitive jaw is estabHshed at the end of the second fetal month. The 
bone, first forming an open gutter beneath the tooth folHcles, soon sur- 
rounds their lateral walls and finally encloses each follicle in a separate 
compartment, the sides arching over and almost completely enclosing the 
developing teeth. This condition is reached between the seventh and 
eighth months after birth. Almost simultaneously absorption of the bone 
begins, caused by the advancement of the erupting teeth. Most of the 
temporary teeth erupt soon after their crowns have been completed. 
The region where the tooth is to erupt is marked by a whitish appearance, 
the mucous membrane is then penetrated and the cutting edge of the tooth 
appears in the mouth. As the crown advances, the root becomes more 
and more calcified and in the majority of instances by the time the crowns 
are fully erupted the roots are also completely formed. At the same time 
rebuilding of the bone takes place and it rapidly fills in about the roots of 
the teeth. When the tooth has assumed its final position it is firmly 
supported by the newly-formed alveolar process. The teeth usually 
erupt by pairs. The central incisors come first, then the laterals and then 
the molars. The cuspids usually appear next and finally the second 
molars take their places. Generally at the end of the second year all the 
temporary' teeth are erupted. 

Figure 8. 

Progress of Decalcification at yearly intervals, 

Decalcification of the Temporary Teeth. The temporar}^ teeth remain 
intact only a short time and the process of decalcification, beginning about 
the fourth year at the apices of the central incisors, follows the order of 
their eruption. The process is completed in about three years, when the 
remainder of the tooth is cast off or shed. Figure 8 gives an idea of the 
relation between the age of the child and the process of decalcification. 


Calcification of the Permanent Teeth. Of the permanent teeth, it is 
the six-year molar in which calcification first begins, the cusps having 
started to calcify at the time of birth. The other teeth foUow corres- 
pondingly, as illustrated in Figure 9. All the teeth are fully calcified 
between the eighteenth and twentieth years. 

Figure 9. 

Progress of Calcification of the Permanent Teeth. 

Eruption of the Permanent Teeth. The formation of the permanent 
teeth occurs above and below the temporary ones and on the lingual side. 
They take up part of the space formerly occupied by the roots of the 
temporary teeth, but the large crowns, having hardly enough room in the 
child's jaws, are pushed way down to the inferior border of the mandible, 
or high up in the maxilla. This is especially true of the cuspids, the roots of 
which are almost completely calcified at the time of the tooth's eruption. 
Gradually the crowns of the permanent teeth force their way to the 
surface. The first permanent molars erupt about the sixth year, behind 
the second temporary molars. Then the crowns of the temporary incisors 
are cast off, being succeeded by the permanent ones. The bicuspids take 
the place of the temporary molars, which are lost between the tenth and 
eleventh years. At about the age of twelve, the second molars erupt. 
The cuspids replace the temporary cuspids between the twelfth and 
thirteenth years and in the fifteenth year we find twenty-eight fully 
erupted teeth. Normally the third molars erupt between the eighteenth 
and twentieth years, but may be retained, according to the accommoda- 
tions afforded by the growth of the jaws. They are fully calcified before 
they make their appearance in the mouth. At the age of twenty, there- 
fore, we should find in a normal case all the thirty-two teeth entirely 
erupted and the roots fully formed; that is, dentition should be 


Chronology of Human Dentition. The approximate time of the 
beginning and completion of calcification, eruption, decalcification and 
loss of the teeth is given in the following table. Variations from these 
dates are, however, very common. As it is often of greatest importance 
to know^ the condition exactly in order to decide on the advisability of 
extracting or retaining a temporary tooth, to determine whether the root- 
canals are completed, or to discover whether the apical foramen is widely 
open or closed, it is wdse to diagnose the case by means of a Roentgenogram, 
which discloses the exact condition. 






of Eruption 

tion Begins 

Tooth Shed 

Central incisor 

4th fetal 

1 7 th- 1 Sth post- 
natal month 

6th-8th post- 
natal month 

4th year 

7th year 


Lateral incisors 

4th fetal 

I4th-i6th post- 

ist-gth post- 

5th year 

Sth year 



natal month 

natal month 



Sth fetal 

24th post- 

lyth-iSth post- 

gth year 

1 2 th year 


natal month 

natal month 


I St molars 

Sth fetal 

iSth-20th post- 

i4th-i5th post- 

6th-7th year 

I Gth year 


natal month 

natal month 

2d molars 

5th-6th fetal 

2oth-2 2nd post- 

i8th-24th post- 

7th-8th year 



natal month 

natal month 


Central incisor 

ist year 


7th-8th year 


Lateral incisor 

I St year 

loth-iith year 

7th-8th year 



3d year 


i2th-i3th year 

1st bicuspid 

4th year 


loth-iith year 


2d bicuspid 

5th year 

iith-i2th year 

iith-i2th year 


1st molar 

Sth fetal month 

9th-i6th year 

6th-7th year 


2d molar 

Sth year 


i2th-i4th year 

3d molar 

gth year 

i8th-2oth year 

i7th-2oth year 

The mandibular teeth precede those of the maxilla by short intervals. 

2. The Normal Adult Jaw and Teeth 

The two jaws, the maxilla and the mandible, are very dissimilar in 
their make-up. Not only does this apply to their shape and appearance, 
the former being irregular and the latter resembling, more or less, a flat 
bone, but especially do they vary in structure. They are both covered by 
periosteum, through which the bone receives part of its nourishment. 
In a Roentgen picture the periosteum is not visible if the bone is normal, 


but becomes apparent when there is an exudate beneath it or when it is 
inflamed or thickened. 

The Maxilla. The maxiUary bone encloses a large cavity, the maxil- 
lary sinus. Its walls, therefore, are very thin. The teeth are contained 
in the alveolar process, which is made up of an outer and an inner plate 
of hard, solid bone called cortex. The outer plate is very thin and frail, 
especially over the apices of the central incisors, cuspids and bicuspids, 
so that abcesses occurring in these regions readily find an outlet to the 
surface and cause a minimum amount of bone destruction. Further 
back the bone becomes thicker and we usually find it massive over the 
second molar, where the zygomatic process has its origin. There are as 
many alveolar sockets as there are roots of teeth. These sockets in their 
normal condition are covered with a layer of dense bone, which is called 
the stratum durum and is shown in Figures i8 and 27. In a Roentgeno- 
gram this dense, hard bone, which is very radiopaque, shows as a light 
line. Posterior to the teeth we find a rounded eminence, the maxillary 
tuberosity (see Figure 20). The inner part of the bone is cancellous and 
consists of medullary spaces surrounded by trabeculae of bone, which 
form a reticular structure. These trabeculae, being radiopaque, show in 
the Roentgenogram as light lines forming a lattice-work which encloses 
darker areas, representing the enclosed radiolucent spaces (see Figure 19). 

The Maxillary Sinuses, These sinuses vary considerably in size, 
shape and capacity. Usually, in order to get an idea of their form, a 
frontal and a lateral Roentgenogram are necessary. The posterior and 
anterior walls are crossed by the alveolar nerves and vessels, which are 
usually contained in bony canals, into which they enter by special foramina 
(see Figure 21). The bicuspids and molars are in close relation to the 
antra and frequently the apices extend through their floors and cause small 
prominences covered by a thin layer of bone and mucous membrane (see 
Figures 18 and 19). 

When healthy, the maxillary sinuses are extremely radiolucent and, 
therefore, show dark in the negative. It is important to always Roentgen- 
ograph both antra, so that they may be compared (see Figure 22). 

The Mandible. The mandible consists of a body and two rami. The 
body which supports the teeth is the part with which we are particularly 
concerned, but the ramus is also important as it is not infrequently 
affected by disease. The mandible is made up of an extremely thick, 


Strong cortex, consisting of an inner and an outer plate, both of which are 
much stronger than those of the maxilla (see Figure 26). In the molar 
region the bone is reinforced still more by the massive internal and external 
oblique lines. The construction of the cancellous part is like that of the 
upper jaw and is shown in Figures 24 and 27. The ramus of the mandible 
is similar in make-up to the body. Its size and massiveness vary accord- 
ing to the individual. 

The Mandibular Joint. The joint of the lower jaw is made up of 
the condyloid process of the mandible, the glenoid fossa and the joint 
disc placed between the two articulating surfaces. It is sometimes 
extremely difficult to get a satisfactory Roentgen picture of this joint, 
but when obtained it is of great help in cases of fracture of the condyle 
or dislocations (see Figure 28). 

The Mandibular Canal. This canal starts from the mandibular fora- 
men and can easily be traced in a good Roentgenogram. The knowledge 
of its relation to the teeth is often of greatest importance in avoiding injury 
of the inferior alveolar nerve and artery. It passes forward immediately 
beneath the alveolar sockets in a horizontal direction until it finds an exit 
at the mental foramen. Here the main canal divides into a number of 
smaller ones, which pass forward to the sockets of the cuspids and incisors. 
The mental foramen lies below and between the first and second biscus- 
pids, usually nearer the second one. The foramen, being a space and, 
therefore, very radiolucent, shows as a dark area especially in an extra- 
oral Roentgenogram and should not be mistaken for an abscess area. 

The Normal Relation of the Teeth to the Jaws. The jaw bones, the 
alveolar processes and the alveolar sockets have already been described 
and it has been pointed out that the latter are lined by a cortical layer of 
bone, the stratum durum, which shows as a light line in the Roentgen 
picture. Between this and the tooth is the periodontal membrane, by 
means of which the tooth is attached to the socket. This, being connective 
tissue, is of high radiolucency and therefore shows as a dark line sur- 
rounding the entire root of the tooth. 

The Teeth in Youth and Old Age. The size of the pulp cavity depends 
upon the age of the tooth. At the time of eruption, the diameter is about 
equal to one-half of the crown, the root-canal being widest at the apical 
part, where it presents a funnel-shaped opening (see Figure 30). After 
the apical part is completely formed there is still a good-sized root canal 


(see Figure 31), but all through life a gradual reduction in size goes on, 
due to the deposit of new dentine by the odontoblasts. This process is 
hastened by certain conditions such as decay and the presence of large 
metal fillings, probably as a protective measure. In old age, and some- 
times earlier, on account of conditions such as those just mentioned, we 
often find the canals of minute size and even obliterated entirely (see 
Figure 32). 

Roentgenology of Tooth Development 

Figure 10. 

Specimen: Fetus, six months old. 

Roentgen Examination : Note Meckel's cartilage, bone formation of the 
jaws and small tooth plates indicating the beginning of calcification of 
the temporary teeth. 


Figure 10. 


Roentgenology of Tooth Development 

Figure ii. 

Patient: A. H., girl three years old. 

Roentgen Examination: All the temporary teeth have erupted. 
The calcification of the permanent cuspid and first molar has reached 
about two-thirds of the crowns. The tip of the first bicuspid is seen 
between the roots of the first temporary molar in the lower jaw. 

Figure 12. 

Patient: H. S., girl four years old. 

Roentgen Examination: Here we find further progress in tooth 
development. The roots of the first temporary molar have been con- 
siderably absorbed. Calcification of the cuspid, first bicuspid and first 
permanent molar has further advanced. 


Figure ii. 

Figure 12. 


Roentgenology of Tooth Development 

Figure 13. 

Patient: E. L., boy five years old. 

Roentgen Examination: Shows the first permanent molars partly 
erupted, but not yet in occlusion. The roots are not entirely formed. 
The crowns of both bicuspids are found between the roots of the temporary 
molars, which have become partly decalcified. The second molars have 
their crowns half formed. 

Figure 14. 

Patient: W. C, girl seven years and eight months old. 

Roentgen Examination: The development of the permanent teeth 
has progressed still further and the roots of the temporary molars are 
two-thirds absorbed. The first permanent molar is in occlusion and its 
roots are almost finished. 


Figure 13. 

Figure 14. 


Roentgenologj^ of Tooth Development 

Figure 15. 

Patient: F. G, girl ten years old. 

Roentgen Examination: The first temporary molar has been shed in 
the lower jaw and the first bicuspid is about to erupt. The roots of the 
second temporary molar are almost entirely absorbed. The roots of 
the cuspid^, first and second bicuspids and second permanent molar are 
still only partly formed, while the roots of the first permanent molar 
are completed. Note that the third molars have started to become 

Figure 16. 

Patient: G. S., girl twelve years and eight months old. 

Roentgen Examination: All the temporary teeth have been shed and 
the permanent ones have taken their places. The second permanent 
molars are just erupting. In the upper jaw we can see the formation of 
the third molar, but in the lower jaw there is no sign of it. 


Figure 15. 


Roentgenology of the Maxilla 

Figure 17. 
Specimen: Dry skull. 
Photograph: Shows the outer aspect of the bone. 

Figure 18. 

Specimen: Dry skull with outer cortical plate removed and antrum 

Photograph: Shows inner structure of bone and relation of the teeth 
to the maxillary sinus. Note the stratum durum surrounding the roots. 

Figure 19. 

Specimen: Dry skull shown in Figures 17 and 18. 
Roentgen Examination: Shows the make-up of the inner part of the 
bone and the relation of the teeth to the maxillary sinus. 



Figure iS. 

Figure 19. 


Roentgenology of the Maxillary Sinuses 

Figure 20. 
Patient: Mrs. L. 

Roentgen Examination: Shows the maxillary tuberosity posterior 
to the third molar. Note its cancellous structure. 

Figure 21. 

Specimen: Frontal section through the human head. 
Roentgen Examination: Shows the outline of the maxillary sinuses 
and the small canals which contain the alveolar vessels and nerves. 


Figure 20. 



Roentgenology of the Maxillary Sinuses 

Figure 22. 
Patient: Mr. W. V. 

Roentgen Examination: Shows both of the maxillary sinuses, as well 
as the ethmoidal and frontal sinuses in normal condition. 



Roentgenology of the Mandible 

Figure 23. 
Specimen: From dry skull. 
Photograph: Shows outer aspect of bone. 

Figure 24. 

Specimen: From dry skull, with cortical plate of mandible removed. 

Photograph: Shows inner structure of bone. The stratum durum 
lining the alveolar sockets is especially well shown on the two biscupids. 
The mandibular canal is partly exposed. 

Figure 25. 

Specimen: From dry skull shown in Figures 23 and 24. 

Roentgen Examination: Shows also the inner make-up of the bone. 
The stratum durum is seen as a white line and is well shown between 
the bicuspid and molar. Note the relation of the third molar to the 
mandibular canal. 


Figure 23. 

Figure 24. 


Roentgenology of the Mandible 

Figure 26. 

Specimens: Cross sections of mandible. 

Photograph: Shows on left a cross section through bicuspid region. 
Note the thick cortical bone and cancellous inner part; also the mandib- 
ular canal and mental foramen. On the right a cross section of the 
front of the mandible is shown. 

Figure 27. 

Specimen: From dry skull with teeth extracted. 

Photograph: Shows the make-up of the bone. Note the thick cortical 
layer at lower border and thinner cortical layer at alveolar margin. The 
sockets are also lined by cortical bone, the stratum durum. 


Figure 26. 

Figure 27. 


Roentgenology of the Mandible 

Figure 28. 
Patient: Mrs. N. 

Roentgen Examination: Shows normal mandibular joint, coronoid 
process and mandibular notch. 

Figure 29. 
Specimen: From dry skull. 

Roentgen Examination: Shows mandibular canal and distribution 
to the teeth. 


Figure 28. 

Figure 29. 


Roentgenology of Normal Teeth 

Figure 30. 

Patient: Miss J., age 11. 

Roentgen Examination: Shows the roots of the first molar finished, 
roots of the second bicuspid and second molar not yet completed and 
the foramen wide open. Note size of the pulp canals. 

Figure 31. 
Patient: Miss G., age 24. 
Roentgen Examination: Shows teeth with normal sized pulp canals. 

Figure 32. 
Patient: Mrs. B., age 48. 

Roentgen Examination: Shows pulp chambers very much smaller 
and root canals decreased in size. 


Figure 30. 

Figure 31 


Figure 32. 



AFTER having studied the appearance of the normal and healthy 
oral tissues as they appear in Roentgenograms, we have a standard 
with which we can compare Roentgenograms of the same parts changed 
by disease. The Roentgenologist should have an intimate knowledge 
of the pathologic conditions such as they appear post mortem, as well 
as under the microscope, although it is only the grosser pathology which 
can be recognized in the Roentgen picture. 

We have come to rely so much on Roentgenograms that we are apt 
to forget that the Roentgen method does not replace all the other means 
of diagnosis. It should be used in addition to digital and instrumental 
examination, occular inspection, transillumination, chemical, thermal 
and electrical tests. 

In examining a Roentgenogram with reference to disease, the inter- 
pretation depends a great deal upon a thorough and systematic search 
for abnormal conditions and upon the anatomical and pathological 
knowledge and the Roentgenographic experience of the interpreter. 
The Roentgenologist's judgment is rendered valuable by his ability to 
associate conditions seen in Roentgen plates with the changes which 
disease produces in the radiability of the tissues. 

1. Irregular Eruption of the Teeth 

The use of the Roentgen ray is particularly applicable to the diag- 
nosis of misplaced, unerupted, impacted, supernumerous or missing teeth. 
The radiability of a tooth is so much less than the surrounding tissue 
that it stands out in a Roentgenogram in a characteristic manner which 
makes its size and shape easily recognizable. However, teeth often 
escape notice, especially if they are far from their normal position. This 
teaches us to be careful not to make a negative diagnosis from intraoral 



films, but to procure a Roentgenogram which shows the entire extent of 
the maxillary bones. 

Misplaced Teeth. Unerupted teeth may be found in any part of 
the maxilla or the mandible and it is important to include in the Roent- 
genogram such places as may harbor them; namely, the nasal cavity, 
the maxillary sinuses, the lower border of the mandible and the entire 
ramus (see Figures 33 and 190). 

Unerupted, Impacted Teeth. Roentgen pictures are not only very 
useful in determining whether a missing tooth is unerupted and impacted, 
but are also an aid in studying the relation of such a tooth to the sur- 
rounding parts in order to decide on the mode of operation which is re- 
quired. The Roentgenogram should, therefore, show the entire outline 
of the tooth and include a fair amount of the surrounding tissues. Un- 
erupted and impacted teeth may be found in various positions and although 
they often lie dormant for years, they may at any time become associated 
with neuralgia or dull pains in any part of the head or neck. Their efforts 
to grow to the surface are usually intermittent, which accounts for the 
fact that the symptoms are not constant. The pressure which they 
frequently bring to bear on the tissues towards which they are growing 
causes at times a physio-pathological absorption of the parts most easily 
dissolved, so that part of the distal surface of the second molar root may 
become eaten away from the pressure of the cusp of an unerupted wisdom 
tooth. Infectious processes are often associated with these conditions 
and may start from a blind abscess on a neighboring tooth, from a pocket 
on the gum or through the blood. The process of inflammation some- 
times takes a chronic course with intermittent, subacute attacks, or it 
may be acute from the start. It then involves the surrounding tissues and 
if it is in the back of the mouth, it may cause inflammation of the fauces 
and the muscles about the ramus. Pharyngitis and trismus of the muscles 
of mastication are commonly sequels to an infection from an impacted 
wisdom tooth. 

The lower third molar is the tooth which is most frequently impacted, 
but the upper third molar is also often in an irregular position. In both jaws 
the tooth may become impacted beneath the equator of the crown of the 
second molar, but in the lower jaw there is an additional obstacle, namely, 
the ascending ramus which is the terminal boundary of the part of the 
mandible which accommodates the teeth. The cuspid teeth are the 


next in the series which are most Hkely to be impacted, but any tooth, 
either in the upper or the lower jaw, may become so. It is unusual for 
temporary teeth to be impacted, but this also happens at times. 

Partially Erupted, Impacted Teeth. Difficult eruption and partial 
impaction occurs c^uite often, especially in the wisdom teeth, and we are 
able to discover the presence of a tooth by the part which extends through 
the gum. However, a Roentgenogram is needed to determine its size 
and position. Partly erupted, impacted teeth are very Hable to become 
infected, on account of the entrance of the fluid of the mouth into the 
wound made by the erupting cusp. The infection passes rapidly into the 
deeper tissues, because the soft tissue does not adhere to the enamel 
of the crown and leaves a pocket which offers a splendid chance for infec- 


In certain conditions the temporary teeth remain and are not replaced 
by permanent ones. This happens when the permanent teeth are con- 
genitally absent and also in cases in which the permanent teeth are 
prevented from eruption on account of impaction or misplacement. 
While we occasionally fmd that such temporary teeth remain for a long 
time without becoming loose, we more often see in the Roentgen picture 
that the absorption of the roots proceeds as usual whether the permanent 
tooth is impacted or missing. 

Congenital Absence of Temporary and Permanent Teeth. There are 
many cases in which the permanent teeth are congenitally absent and 
usually there is a historv* that there were no temporary ones either. This 
is considered by many writers as a sign of a reduction in the human 
dentition. It is especially the third molars and the lateral incisors which 
are found to be missing. The importance of Roentgen diagnosis in such 
cases is apparent, as it prevents the possibility of disturbances being 
caused under a bridge or a plate by the late eruption of a tooth which 
was believed to be absent (see Figures 287-291). 

Supemumerous Teeth. ]\Ian normally has thirty-two teeth. This 
is a considerable reduction from the mammalian formula, which includes 
twelve incisors, four cuspids, sixteen bicuspids and sixteen molars in some 


species. It is believed that supernumerous teeth are a retrogression or 
falling back upon the formula of a lower type, but there are also so-called 
rudimentary peg-shaped teeth which appear occasionally in the dental 
arch. These are caused by epithelial remnants, parts of the tooth band 
forming a primitive enamel organ into which a connective tissue papilla 
grows, so forming, by an analogous process, as in tooth development, 
more or less well-formed supernumerous teeth. 

Roentgenology of Misplaced Teeth 

Figures 33 and 34, 

Patient: Mr. F. S., courtesy of Dr. Gibbons. 

History: One year previous to the discovery of the tooth the patient 
began to suffer periodically from headaches, no local pain whatever being 
present. He had a bad taste in the mouth every morning and a sinus 
opening just back of the second molar was found, from which half a dram 
of pus was discharged in twenty-four hours. 

Roentgen Examination: Figure 23 shows side view with probe inserted 
into the sinus. 

Roentgen Examination: Figure 34 shows front view of same. 


Figure i,i,. 

FlGtJRE 34. 


Roentgenology of Unerupted and Impacted Teeth 

Figure 35. 
Specimen: Shows partly erupted, impacted lower thhd molar. 

Figure 36. 
Roentgenogram: Shows similar condition. 

Figure 37. 
Specimen: Shows unerupted, impacted lower third molar. 

Figure 38. 
Roentgenogram: Shows similar condition. 

Figure 39. 
Patient: MissB.D. 

History: Complained of indefinite pressure in jaw which made her 
extremely nervous; also pain in back of neck. 

Roentgen Examination: Shows unerupted lower third molar. 
Result of Operation: Symptoms disappeared entirely. 


Figure 36. 

Figure 38. 

Figure 39. 


Roentgenology of Unerupted and Impacted Teeth 

Figure 40. 
Patient: Mr. F. P., age 17. 

Roentgen Examination: Shows unerupted and incompletely formed 
third molar. 

Figure 41. 

Patient: Same person two years later. 

Roentgen Examination: Shows that the tooth has changed its position 
and has become impacted. 

Figure 42. 
Patient: Dr. B. 

History: Tooth gave no trouble for several months after its discovery, 
but suddenly began to cause neuralgic pain. 

Roentgen Examination: Shows unerupted, impacted third molar. 


Figure 40. 

Figure 41. 

Figure 42. 


Roentgenology of Unerupted and Impacted Teeth 

Figure 43. 

Patient: Mr. R. B. F. 

History: Had repeated trouble with left lower wisdom tooth. The 
last attack was the worst, being accompanied by large swelling, difficulty 
in swallowing, trismus of muscles of the jaw and pus discharge around 
the tooth. 

Roentgen Examination: Shows an impacted lower third molar with 
large cavity in crown, apparently involving the pulp and causing an 
apical abscess, as indicated by the radiopaque area around the apex of 
the root. 

Figures 44-46. 

History: All three cases had pus pockets and caused more or less 
inflammation of the surrounding tissues. 

Roentgen Examination: Figure 44 shows an upright lower third 
molar, impacted in the ramus, with a radiopaque area indicating a pus 
pocket. Figure 45 shows an unerupted obliquely impacted third molar. 
Figure 46 shows an unerupted third molar tipping backwards. The 
radiopaque area around the crown indicates a pus pocket. 

Figure 47. 
Patient: Mr. T. M. S. 
History: Has ringing and aching in ear. 
Roentgen Examination: Shows impacted third molar. 

Figure 48. 
Patient: Mrs. B. S. 
History: Has pain in back of neck. 
Roentgen Examination: Shows unerupted third molar on both sides. 

Figure 49. 
Patient: Miss A. W. 
Roentgen Examination: Shows unerupted, malposed cuspid. 


Figure 43. 


Figure 44. 

Figure 45. 

Figure 46. 

Figure 48. 

Figure 49. 


Roentgenology of Unerupted and Impacted Teeth 

Figure 50. 

Patient: Mrs. E. L., age 37. Courtesy of Dr. J. M. Levy. 

History: Suffered from headaches for a considerable number of years 
without being able to secure any permanent relief. 

Roentgen Examination: Shows impacted third molar. 

Operative Findings: Second and third molars had to be extracted. 
The distal root of the second molar had been completely absorbed and 
the distal surface of the mesial root also showed evidence of absorption. 

Result of Operation: Patient improved a great deal, but was not 
entirely relieved of headaches. 

Figure 51. 

Patient: Dr. E. S. W. 

Roentgen Examination: Shows unerupted, impacted lower molar. 
Its position leads to the conclusion that the distal root of the second molar 
has been partly absorbed. 


Figure 50. 

Figure 51 


Roentgenology of Unerupted and Impacted Teeth 

Figure 52. 

Patient: Mrs. T. A. 

Roentgen Examination: Shows wisdom tooth tipping forward. The 
roots of the second molar, which apparently was not entirely erupted, 
are impacted. 

re 53. 
Patient: Miss E. E. 

Roentgen Examination: Shows unerupted third molar and unerupted 
impacted second molar. 

Figure 54. 

Patient: Miss C. K., age about 12 years. 

Roentgen Examination: Shows lower second temporary molar im- 
pacted with root absorbed and second bicuspid unerupted. 

Figure 55. 

Patient: Miss W., age about 10 years. 

Roentgen Examination: Shows upper temporary second molar impacted 
with roots absorbed. The permanent teeth are present and show normal 

Figure 56. 

Patient: Master K., age about 12 years. 

Roentgen Examination: Shows lower temporary second molar un- 
erupted and impacted, the roots being absorbed. The second bicuspid 
seems to have rudimentary form. 

Figure 57. 

Patient: Miss G. S., 12 years old. 

Roentgen Examination: Shows unerupted, impacted lower second 
bicuspid. The impaction is probably due to early loss of the second 
temporary molar. 



Figure 52. 


Figure 54. 

Figure 56. 

Figure 57. 


Roentgenology of Unerupted and Impacted Teeth 

Figure 58. 
Patient: Miss C. 
Roentgen Examination: Shows impacted and unerupted upper cuspid. 

Figure 59. 

Patient: Miss M. S., age 14 years. 

Roentgen Examination: Cuspid did not erupt and was found in the 
position shown in the Roentgen picture. 

Figure 60. 

Patient: Miss R. 

History: Had several old roots in upper jaw and pus discharge from 
various sinuses. 

Roentgen Examination: Shows two unerupted cuspids with radiolu- 
cent areas, indicating abscess conditions, which apparently caused decay 
of the crowns of the teeth. Note their appearance as compared with 
other impacted teeth. 

Operative Findings: The two cuspids were surrounded by abscess 
tissue and probably had become infected from the other teeth. The bone 
was necrotic and the teeth decayed at the crown. 

Figure 61. 

Patient: Mrs. J. C. 

History: Had pain and swelling in cuspid region of lower jaw. Pus 
Avas discharged from a sinus. 

Roentgen Examination: Shows unerupted cuspid. Radiolucent area 
around crown of tooth indicates abscess condition and the appearance 
of the crown itself points to decay of the tooth. A small radiolucent 
area at the end of the bent root indicates abscess formation. 



Figure 59. 

Figure 60. 

Figure 61 


Roentgenology of Retained Temporary Teeth ; Permanent Ones Missing 

Figure 62. 

Patient: Mr. G., age 26 years. 

Roentgen Examination: Shows that the retained temporary tooth 
has an absorbed root, the permanent tooth being absent. 

Figures 63-66. 

Patient: Mr. W. C. B., age 28 years. 

Roentgen Examination: On the right upper side the second temporary 
molar has been retained. Its roots are entirely absorbed and both per- 
manent bicuspids are absent. On the left upper side, both temporary 
molars have been retained. The same is true of the left lower side. 
In neither of the pictures is there any evidence of the permanent teeth. 
Also, on the right lower side, the bicuspids are absent. The temporary 
teeth have been shed, except for a small piece of root. 

Figure 67. 

Patient: Miss B. T., age 14 years. 

Roentgen Examination: The retained second temporary molar shows 
only slight absorption of the roots. There is no bicuspid present. 


Figure 62. 

Figure 63. 

Figure 64. 


Figure 6= 

Figure 66. 

Figure 67. 


Roentgenology of Retained Temporary Teeth; Permanent Ones 

Figure 68. 
Patient: Miss M. C. 

Roentgen Examination: Shows temporary cuspid partly absorbed. 
Permanent cuspid unerupted and impacted. 

Figure 69. 

Patient: Mr. H. 

Roentgen Examination: Shows that the unerupted permanent bicuspid 
is growing in the wrong direction and is impacted. The temporary 
molar, which has been retained, shows absorption of the roots. 

Figure 70. 

Patient: Mrs. B. 

Roentgen Examination: Shows that the permanent cuspid is un- 
erupted and impacted and the temporary cuspid shows absorption of the 
root. The permanent cuspid is pressing against the root of the lateral 
incisor, causing it to tip distally. 




Figure 68. 

Figure 69. 

Figure 70. 


Roentgenology of Missing and Supernumerous Teeth 

Figure 71. 
Patient: Miss Sy. 
Roentgen Examination: Shows absence of both upper lateral incisors. 

Figure 72. 

Patient: Master M., age 12 years. 

Roentgen Examination: Shows both temporary and permanent lat- 
eral incisors missing on left side. The picture shows the permanent 
central incisor, the temporary cuspid root, partly absorbed and the 
permanent cuspid about two-thirds formed. 

Figure 73. 
Patient: Mrs. W. 

Roentgen Examination: Shows unerupted third molar and rudimen- 
tary fourth molar. 

Figure 74. 
Patient: Mr. J. F. 

Roentgen Examination: Shows first molar supplied by bridge and 
behind third molar a small rudimentary fourth molar. 


Figure 71. 

Figure 74. 

Figure 72. 


2. Diseases of the Hard Tooth Substances 

The diseases of the hard tooth substances are nearly always obvious, 
with the exception of affections of the root ends, which will be discussed 
in connection with alveolar abscesses. There are cases, however, where 
the Roentgen ray is useful in diagnosis. 

Abrasion. This is a physiological process, the tooth having been worn 
down from mastication. In these days, when almost all of our food is 
cooked and soft, we rarely find bad cases of abrasion, but with our ances- 
tors it was the greatest etiological factor in the involvment of the pulp 
and of alveolar abscesses, as is evidenced in the skulls of the ancient Egyp- 
tians and various tribes of the old as well as the new world. Abrasion 
also occurs sometimes on single teeth, due to malocclusion or loss of the 
supporting back teeth. P'rom a Roentgenogram we can get an idea 
of how far the process has progressed toward the pulp chamber and how 
much the pulp has receded. This is important to know when restauring 
lost tooth substance or if making appliances to protect the tooth from 
further harm. 

Fractures. Teeth which have received traumatic injury from blows, 
falling, accidents, etc., should always be Roentgenographed, as fractures 
occur quite frequently below the surface of the gum and cannot always 
be diagnosed by digital examination. Front teeth are most frequently 
injured and the line of fracture is generally in a horizontal direction. 
Roots to which porcelain crowns are attached by means of posts, how- 
ever, split vertically. If the vertical fracture lies in a labio-lingual or 
bucco-lingual plane, it can be easily demonstrated on the Roentgen film, 
while the disto-mesial fracture is not always visible in the Roentgenogram. 

Caries. This most frequent dental disease is, as a rule, easily recog- 
nized, but at times obscure decay may be discovered in a Roentgenogram 
under a gum margin or beneath a filling or crown, causing neuralgia or 
sensitiveness to heat, cold and sweets. The Roentgen picture also 
depicts accurately the amount of pulp recession and the deposit of second- 
ary dentine, due to the process of decay (see Figure 83). 

Odontomata. A tumor of the teeth is made up of the various tooth 
tissues, one or more of which may enter into its composition. It may be 
attached to another tooth or made up of two or more teeth fused together; 


sometimes they are undefined masses, held together by cementum. 
The latter are more dangerous, as they may attain great size and dis- 
figure the face. They are also liable to crowd the teeth out of position, 
and cause neuralgia. The Roentgen diagnosis is important in such 
cases, as it helps to differentiate the odontoma from other conditions, such 
as osteoma, osteosarcoma and cysts. 



Roentgenology of Abrasion 

Figure 75. 
Specimen: From dry skull. 

Photograph: Shows mandible with abrasion of the teeth, the pulp 
of the first molar having become exposed. 

Figure 76. 

Specimen: From dry skull shown in Figure 75. 

Roentgen Examination: Shows close relation of the occlusial surface 
with pulp chamber. A radiolucent area at the ends of the roots of the 
first molar indicates abscess conditions, due to exposure of the pulp. 

Figure 77. 
Patient: Mr. McK. 

Roentgen Examination: Shows that the pulps have receded a con- 
siderable distance on account of abrasion. 

Figure 78. 
Patient: Mr. T. B. 

Roentgen Examination: Abrasion of the front teeth has caused the 
pulps to recede. 

Figure 79. 
Patient: Mr. P. G. 

Roentgen Examination: Shows the relation of the pulp of the molar 
to the worn-off occlusial surface. 


Figure 75. 

Figure 76. 

Figure 77. 

Figure -ji 


Figure 79. 


Roentgenology of Tooth Fractures 

Figure 80. 

Patient: Mr. W. 

History: Patient received blow sometime ago and the tooth had 
to be devitalized and the root canal filled. An abscess formed, however^ 
causing swelling of gum and soreness. 

Roentgen Examination: Shows fractured root with root canal filling 
in lower part. The radiolucent area bet'\\^^n and around the fracture 
indicates an abscess condition. 

Figure 81. 
Patient: Mr. R. S. C. 

History: Patient was hit with hockey stick. Considerable swelHng 
on gum and some pain. The tooth was very sore. 
Roentgen Examination: Shows fractured root. 

Figure 82. 

Patient: Mr. McK. C. 

History: Patient was in motorcycle accident. The upper front 
teeth were slightly broken at edge, the left upper incisor was very tender 
and there was a slight swelling over the gum. 

Roentgen Examination: Shows fracture of root. The small radio- 
lucent area at the apex shows the beginning of an apical abscess. 


Figure 80. 




Roentgenology of Tooth Decay 

Figure 83. 
Patient: Miss W. 

Roentgen Examination: Shows pulps very much receded laterally and towards 
the apex on account of decay. 

Figure 84. 

Patient: Miss P. 

History: Patient complains of ear ache on right side and she also had occasionally 
what she called " face ache " on the same side. No pain in the teeth. She consulted 
two dentists, who could find no trouble. 

Roentgen Examination: Shows large decayed area under filling at distal side of 
right lower second bicuspid. A radiolucent area at the apex of the tooth indicates that 
the pulp had become affected and caused an apical granuloma. 

Result of Operation: After extraction of the tooth and curetting of the bone, the 
symptoms disappeared promptly. 

Figure 85. 

Patient: Mr. C. M. R. 

History: Had arthritis in hip and knee for 2^ years. Teeth apparently sound. 

Roentgen Examination: Besides several other teeth the left lower first bicuspid 
showed a large radiolucent area at the apical part, indicating an abscess condition. This 
was evidently caused by a diseased pulp which became infected by decay. Note the 
radiolucent area under the filling in distal side of tooth. 

Figure 86. 
Patient: Mrs. F. A. S. 

History: Obscure neuralgia, especially in right upper Jaw. 

Roentgen Examination: Shows a radiolucent area on the cervical part of the root 
of the lower second molar and a cavity at the distal side, all concealed under the gum. 
Result of Operation: Extraction of the tooth stopped the neuralgia entirely. 

Figure 87. 
Patient: Mrs. F. A. S. 
History: Pain in left lower jaw. 

Roentgen Examination: Shows decay on distal side of left lower molar, in close 
proximity to the pulp. 

Figure 88. 
Patient: Mrs. W. V. B. 
History: Pain from hot and cold food. 
Roentgen Examination: Shows decay under fiUing of left lower molar. 


Figure 83. 

Figure 84. 


Figure 85. 

Figure 86. 

^ ^ V "^ 

Figure 87. 



Roentgenology of Odontomata 

Figure 89. 

Patient: Mrs. E. B. 

Roentgen Examination: Examination for infectious foci revealed odon- 

Operative Findings: The odontoma was made up of two lower molars 
grown together, one in upright and one in transverse position. The first 
tooth was well formed, the other having the general appearance of a 
lower molar. 




Roentgenology of Odontomata 

Figure 90. 

Patient: Mrs. I. A. V. 

History: Patient had frequent attacks of severe neuralgia. 

Roentgen Examination: Shows lower unerupted and impacted wisdom 
tooth. The wisdom tooth in the upper jaw is also unerupted and has 
an extension of round appearance and radiopaque character at the distal 
part of its neck. 

Operative Findings: When the tooth was removed it was found that 
a round tumor, made up of dentine and covered with cement, was fused 
to its distal side. 


Figure 90. 


3. Diseases of the Dental Pulp and their Sequel, Alveolar 

The Size, Shape and Number of Root Canals. These can only be diag- 
nosed by the Roentgen method and before treatmg a root canal, no matter 
in what condition it is, a Roentgen picture is absolutely necessary. The 
patient and the dentist will save much time and expense if the exact con- 
dition is determined beforehand. Not only is it important to know 
whether the tooth is straight or bent, whether the number of the canals 
is normal or abnormal, whether the apical foramen is unfinished or con- 
tains several outlets, whether the canals are accessible to the very end 
or whether secondary deposits of dentine or pulp stones obstruct suc- 
cessful treatment, but also it is important to ascertain whether a diseased 
pulp has affected the periodontal membrane, the tooth root and the 
surrounding bone, as the treatmeat of such cases would differ widely. 

Pulp Stones. Calcarious deposits in the root canals of teeth are 
frequently the cause of obscure neuralgia. Besides the deposit of second- 
ary dentine, which has already been mentioned, we have the formation 
of pulp stones, a deposit of lime salts in the tissue. These may occur 
in healthy as well as diseased pulps. In the former they appear as well 
defined nodules, while in the latter we often find undefined masses of cal- 
cified, necrosed tissue. Pulp stones, on account of their radiopacity, are 
easily recognizable in the Roentgen negative as light areas in the root canal. 

Inflammatory Processes of the Dental Pulp. These are of micro- 
scopic nature and primarily cause no change which would affect the radi- 
ability of the tissue. It is sometimes possible, however, to diagnose a 
diseased pulp by finding a condition which we know to be a cause of pulp 
disease, such as decay beneath a filling or a pus pocket reaching the apical 
end of an otherwise sound tooth. When looking for the cause of an ob- 
scure pain or an enlarged lymph gland we occasionally find an area around 
the root of a tooth which has no history of pulp removal. The area may 
be well defined and very radiolucent or may only show an indistinct zone 
of induration. Such conditions indicate that the pulp in the tooth has 
become diseased and affected the tissues without. 

The sequels of pulp disease furnish, perhaps, the greatest field for 
oral Roentgenography. There are two chains of pathological changes 


which may result, the first starting as an acute suppurating inflammation 
and the second stimulating new inflammatory growth, which ends in a 
granuloma. It is impossible to tell from a Roentgen picture whether 
a radiolucent cavity in the bone contains pus or granulation tissue or 
whether the process is acute or chronic. 

Acute Periodontitis and Acute Alveolar Abscesses. These are 
sequels of pulp disease which involve destruction of the periodontal 
membrane. The stratum durum of the alveolar socket becomes involved 
and in some cases a large amount of bone may become destroyed, while 
in other cases, where the apex is near the surface and covered by only 
a thin layer of bone, the pus burrows its way cjuickly to the outside, 
finally collecting under the periosteum or gum. The swelling of the soft 
tissue is sometimes cpite considerable and is called subperiosteal or 
subgingival paruhs. Roentgenograms of acute alveolar abscesses at 
times show large radiolucent areas, but quite frecjuently we find no sign 
of an abnormal condition, due to the fact that no bone has been destroyed, 
the pus having collected between the gum and bone. 

Chronic Alveolar Abscess. After the pus has found an outlet to the 
surface, the swelling subsides slowly, but if the cause has not been removed, 
the condition passes into the chronic stage. Inflammatory granulation 
tissue is formed in the bone cavity, which discharges varying quantities 
of pus for months or years. A Roentgenogram of such a condition shows 
a dark area, indicating the radiolucent cavity in the bone filled with 
granulation tissue. Roentgenographically this condition cannot be 
distinguished from the following: 

Proliferating Periodontitis and Dental Granuloma. Xot until the 
Roentgen picture came into use for dental work was it discovered that 
devitalized teeth, although apparently firm and sound and giving no 
discomfort, are the cause of chronic inflammatory processes, harbored 
in the maxillary or mandibular bones. Since the pathology and bacteri- 
ology of these symptomless lesions has been studied more carefully and 
since we know that they are frequently foci of somatic diseases, we have 
discovered the grave fact that these septic conditions are of a most deceiv- 
ing nature and may be more dangerous than abscesses of acute and 
violent character. We also realize now the importance of making a most 
careful search for these lesions, which can usually be diagnosed by the 
Roentgen method. 


Apical Granviloma. The most common seat of these lesions is the 
periapical region, at the outlet of the root cana from which the disease 
starts (see Figure 113). 

Inter radicular Granuloma. The floor of the pulp chamber of multi- 
rooted teeth is sometimes penetrated by burs or root canal instruments, 
causing a granuloma between the roots (see Figure 114). 

Lateral Granuloma. Sometimes teeth have accessory foramina as 
high up as the middle of the root. These may become the source of 
trouble if the pulp is diseased. Granulomata at the side of a root are, 
however, more commonly caused by perforations made with instruments 
(see Figure 115). 

Proliferating periodontitis is caused by the poisonous products of bac- 
terial decomposition and fermentation which stimulate new protective 
growth in the periodontal membrane. It is recognizable at an early stage 
by a thickening at the part where the irritation occurs. The Roent- 
genogram shows an increase in the size of the radiolucent line repre- 
senting the periodontal membrane (see Figures 116-118). 

A granuloma is made up of a fibrous capsule containing granulation 
tissue infiltrated by a large mass of plasma cells, lymphocytes and poly- 
morphonuclear leucocytes. In the center we sometimes find a process 
of destruction which may result in a so-called subacute attack. The 
proliferation goes on until the lesion has grown to about the size of a 
pea, although larger granulomata are not uncommon. The growth of 
the granuloma occurs at the expense of the bone (see Figure 119), and 
being more radiolucent than the latter, it shows as a dark area in the 
Roentgen picture. It must also be remembered that the bone destruction 
is not the only factor. The picture of the radiolucent area depends upon 
the thickness of the bone surrounding it, as well as its make-up. In the 
lower jaw, therefore, on account of the thickness of the two dense bone 
plates, and where only the cancellous part may be destroyed, we will not 
get as dark a picture as we would in the upper jaw, where the buccal or 
lingual cortical plate is generally affected also. While there is, as a rule, 
little doubt in making a Roentgen diagnosis about a single-rooted tooth, 
it is more difficult with the multi-rooted upper teeth. The upper first 
bicuspid should be Roentgenographed from a bucco-mesial direction, 
while two Roentgen pictures are necessary to show distinctly the condition 
of the two buccal roots and the palatal root of a molar. The first is 


taken about perpendicular to a plane drawn through the buccal roots 
and the second perpendicular to the palatal root. 

Subacute Attacks. If the destructive process becomes severe, a 
subacute attack may occur with a large amount of pus collecting under 
the periosteum or gum, the patient experiencing symptoms of acute 
inflammation. Roentgenograms of such conditions usually reveal only 
a small radiolucent area, although the accumulation of pus under the gum 
may be quite considerable. This is due to the fact that it is not the pus 
which shows in the picture, but the bone destruction. The tooth causing 
the trouble will be found to be devitalized and treated, which differentiates 
it from the acute attack occurring on a tooth, the pulp of which has only 
been diseased a short time and where there is no evidence of previous 
root canal work. 

Results of Alveolar Abscesses on the Root Apex. Acute or chronic 
inflammation, whether due to acute periodontitis, acute abscess, pro- 
liferating periodontitis or granulomata, if of any duration, leaves its mark 
on the apex of the root. 

Exostosis of the Root Apex. Chronic inflammation is a continued 
irritation and causes stimulation of the cementoblasts, which produce new 
cementum. This results in h}^ercementosis, which is usually restricted 
to the seat of the disease, that is, the apex of the root. This thickening 
or bulging of the root is called exostosis and makes extraction of the 
tooth an extremely difificult operation. The condition, if occurring in the 
mesiodistal direction, is easily recognizable in the Roentgenogram by the 
abnormal form. 

Necrosis of the Root. If the apical part of the periodontal membrane 
has become destroyed, the blood supply of the devitalized tooth is doubly 
cut off. The cement becomes infected and shows a rough surface. In 
this condition it is an obnoxious foreign body, which nature tries to 
eliminate. A process of absorption starts at the apex, similar to the process 
of necrosis in bone, but while in bone such parts become separated and 
are expelled as sequestra, in a tooth the root becomes more and more 
absorbed and the whole organ has to be considered as the sequestrum. 
In the Roentgen picture, necrosis of the tooth root is recognized by the 
poorly defined outline at the apex and, in the later stages, by actual loss 
of part of the root. 


Roentgenology of Pulp Canals 

Figure 91. 

Specimen: Prepared skull, reproduced by courtesy of Dr. Hopewell- 

Photograph: Shows normal pulp canals. 

Figures 92-95. 
Roentgen Examination: Shows abnormally formed roots. 

Figure 96. 

Roentgen Examination: Shows two root canals in lower second 

Figure 97. 

Roentgen Examination: Shows accessory canal in apical part of root 
of an upper central incisor. 

Figure 98. 

Roentgen Examination: Shows pulp canal of lower second bicuspid 
and second molar wide open. The patient was about eleven years old. 


Figure 91 

Figure 92. 

Figure 93. 

llLlRF. 04. 

Figure 95. 

Figure 96. 

Figure 97. 

Figure 98. 


Roentgenology of Pulp Stones 

Figure 99. 

Specimen: Dental pulp in situ. Stained with Mallory's phosphotungstic acid 
Hematoxylin. Several pulp stones are shown in the picture. 

Figure 100. 

Patient: Mrs. V. G. L. 

History: Had attacks of neuralgia at intervals on left side of face. For three 
days had been in severe pain, which was especially located in the ear and zygomatic 
region. Blocking of the posterior, superior alveolar nerves with novocain suprarenin 
synthetic stopped the pain at once. 

Roentgen Examination: Shows pulp stones in the upper second and third molars. 

Result of Operation: Removal of the pulp and pulp stones reheved all symptoms. 

Figure loi 

Patient: Mrs. J. B., age about 75 years. 

History: Suffered for years with severe neuralgic pains. Two suspicious teeth, 
which had been extracted previously, proved to have had no effect. Blocking of the 
inferior alveolar nerve stopped the pain. 

Roentgen Examination: Shows pulp stones in both remaining molars. 

Result of Operation: No recurrence of attacks after removal. 

Figure 102. 
Patient: Miss H. 
Roentgen Examination: Shows calcarious deposits in pulp canals. 

Figure 103. 

Patient: Miss E. S. 

History: Patient had been suffering for years with very severe neuralgia on both 

Roentgen Examination: Shows pulp stone in pulp chamber of left lower first molar, 
as well as in other teeth not reproduced. 

Result of Operation: Removal of the pulp stones did not relieve the condition. 


Figure 99. 

Figure 100. Figure ioi. 


Figure 102. Figure 103. 


Roentgenology of Pulp Disease 

Figure 104. 
Patient: Miss K. 

History: Patient complained of soreness and pain in tooth. 

Roentgen Examination: Radiolucent area around each root of the lower second molar, indicating 
apical periodontitis. As there is no other cause, we conclude that the pulp must be diseased. 
Operative Findings: Pulp found to be diseased when opened into. 

Figure 105. 
Patient: Mrs. E. M. 

History: Lower third molar slightly sensitive on percussion with occasional soreness. 
Roentgen Examination: Radiolucent area around root indicating apical periodontitis. FOling 
seems very close to pulp. 

Operative Findings: Pulp necrotic. 

Figure 106. 

Patient: Mr. W. 

History: Tooth is very sore and surrounding tissues inflamed. Heat causes pain. 

Roentgen Examination: Filling superficial. Pus pocket on mesial side and radiolucent area, 
indicating abscess formation around ape.x. From Roentgen examination we may conclude that the pus 
pocket has reached the apical part of the tooth and started an alveolar abscess, causing inflammation of 
the pulp. 

Figure 107. 

Patient: Miss P. 

History: Ear ache on right side and occasionally what she called "face ache" on same side. No 
pain in teeth. 

Roentgen Examination: Shows large radiolucent area indicating decay under filling of right lower 
second bicuspid; also radiolucent area at apex of tooth. From these findings we may conclude that the 
pulp is diseased. 

Operative Findings: Pulp found to be necrotic. 

Figure 108. 

Patient: Mr. C. S. B. 

History: Complained of tenderness under jaw. • No pain and no other symptoms. Examination 
showed swelling of the submaxillary lymph gland, which was quite tender. The two cervical glands 
were also in\olved. Examination of the mouth revealed nothing except large amalgam fillings in the 
posterior teeth. 

Roentgen Examination: A picture of the lower teeth shows a large slightly radiolucent area, extend- 
ing from the roots of the second molar. The inflammatory process has apparently involved only the 
cancellous part of the bone. The cortex is extremely thick in this region and, therefore, the radiability 
is only increased a little. I concluded that the pulp must have become infected in this tooth. 

Operative Findings: On opening the tooth, the pulp was found to be extremelj- putrescent. After 
proper treatment the glands became normal. 

Figure 109. 

Patient: Miss F. G. 

History: Slight amount of pain felt at angle of jaw. Examination of mouth showed well-cared-for 
teeth with large fillings. 

Roentgen Examination: Shows a radiolucent area of well defined character on the roots of the 
lower first molar. A dark area under distal part of filling indicates decay. The conclusion from these 
findings is that the pulp has become infected from the decay and caused apical abscesses. 

Operative Findings: Pulp putrescent with very marked odor of decay. 


Figure 104. 

Figure 105. 

Figure 106. 

Figure 107. 

Figure 108. 

Figure 109. 


Roentgenology of Acute Alveolar Abscess 

Figure no. 

Patient: Mr. G. T. 

History: The upper central incisor had recently been filled on labial surface. The 
tooth started to ache and the condition grew gradually worse. Examination showed 
the left central incisor extremely loose and tender, the two neighboring teeth being 
in similar condition. The gum was swollen and the lip protruded. 

Roentgen Examination: Shows large radiolucent area, apparently starting from 
left central. No indication of root canal work. This leads to the conclusion that the 
pulp became involved and caused an acute abscess. The pus destroyed a large amount 
of bone before breaking through to the surface. 

Figure in. 

Patient: Miss F. B. 

History: While having the teeth regulated, the right upper lateral incisor became 
very sore and there was a large swelling on the gum over this tooth. 

Roentgen Examination: Reveals only slight rarefied area around root apex of this 

Operative Findings: Tooth was opened into under general anesthesia and found 
putrescent. After lancing the gum, a great deal of pus escaped. 

Figure 112. 

Patient: Miss R. M. P. 

History: Had complained of swelling under lip for several days. When examined 
the lip protruded very much and the submaxillary lymph gland was very tender and 
badly swollen. Temperature loi, pulse 102. The front teeth had large fillings, gold 
in the laterals and porcelain in the centrals, and were very loose. 

Roentgen Examination: Shows that the fillings, although large, do not come very 
close to the pulps. There was tremendous swelling, but the Roentgen picture shows 
no radiolucent area, as would be expected with such large abscess formation. 

Operative Findings: The pulp, when opened into, was found to be highly putrescent. 
An incision on the labial side of the gum relieved about an ounce of pus. The apex 
of the tooth must have been very close to the surface, because the pus evidently caused 
no destruction of the bone, but pierced the bone and periosteum (which accounts for 
the absence of pain), and accumulated under the gum. 


Figure iio. 

Figure hi. Figure 112. 


Roentgenology of the Blind Alveolar Abscess or Dental Granuloma 

Figure 113. 
Roentgen Examination: Shows apical granuloma. 

Figure 114. 

Roentgen Examination: Shows two apical and interradicular granu- 
lomata, probably caused by perforation of pulp chambers. 

Figure 115. 

Roentgen Examination: Shows lateral granuloma, caused by perfor- 
ation at the side of the root. 

Figures 11 6-1 18. 

History: None of these three cases caused any discomfort and the 
teeth had been devitalized for varying lengths of time. 

Roentgen Examination: Shows incomplete root canal filhngs. The 
radiolucent area which represents the periodontal membrane is enlarged 
at the apical part, indicating proliferating periodontitis. 



FlGl Kl. 11,1. 

Figure 114. 



Figure 116. Figure 117. 


Roentgenology of the Blind Alveolar Abscess or Apical Granuloma 

Figure iig. 

Specimen: Dry skull showing destruction of bone caused by a granuloma at the root of a devitalized 
second bicuspid. 

Figure 120. 

Roentgen Examination: Shows a similar condition with a radiolucent area at the apex of the tooth, 
representing bone destruction caused by the inflammatory process. 

Patient: Mrs.B. Figure 121. 

Roentgen Examination: Shows large radiolucent area indicating an apical granuloma. The root 
canal is partly filled and divides into two channels at the apex. 

Patient: Mrs. C. H. C Figure 122. 

Roentgen Examination: Shows two radiolucent areas. The one at the apex of the lateral incisor 
represents an apical granuloma, while the other above the central incisor at the mesial side is caused by 
the incisive foramen, as was ascertained in another picture. 

Patient: Mr. S. Figure 123. 

Roentgen Examination: Shows a radiolucent area around the end of the root of the first bicuspid, 
the root canal not being entirely filled. 

Patient: Mr. J. L. S. Figure 124. 

Roentgen Examination: Shows a large radiolucent area, indicating a granuloma caused by the 
devitalized lateral incisor. 

Operative Findings: Apicoectomy was performed and a large cavity, filled with inflammatory 
granulation tissue, was found in the bone. 

Patient: Mrs. W. H. C. Figure 125. 

Roentgen Examination: Shows large radiolucent area representing a granuloma. Note the radio- 
paque substance in its center. 

Operative Findings: Apicoectomy was performed. The bone cavity, as outlined in the picture, 
contained partly necrosed granulation tissue. The radiopaque substance was found to be a piece of 
gutta percha. 

Patient: Mrs. C. A. P'&nre 126. 

History: The tooth was devitalized, treated and filled many years ago. A sinus was found on the 
gum, through which pus discharged at intervals. 

Roentgen Examination: Shows well filled root canal. At the apex, the root is more radiolucent, 
which indicates necrosis. The radiolucent area surrounding the tooth shows the bone destruction. The 
other central incisor, which is also a devitalized tooth, seems to be in normal condition. 

Operative Findings: The bone cavity was found to contain inflammatory granulation tissue and 

Patient: Mr. P. R. P Figure 127. 

Roentgen Examination: Two devitalized teeth are found, the right upper lateral incisor and the 
cuspid with root canals partly filled. Note the large radiolucent area extending waj' down between 
the cuspid and lateral 

Operative Findings: Apicoectomy was performed and a large bone cavity was found, as outlined 
in the picture, filled with inflammatory granulation tissue. 

Patient: Mrs. L. ^ >&'"-<: 128. 

Roentgen Examination: The left lower bicuspid shows a large radiolucent area, indicating an apical 
granuloma, caused by a necrotic pulp. 

Patient: Mrs. j' B.C. Figure i2g. 

History: Patient had lymphangitis. From the left submandibular region the lymph vessels were 
seen as red lines extending to the breast and axilla. The submaxillary and cervical lymph glands were 
swollen. No pain in the teeth. 

Roentgen Examination: Shows a radiolucent area surrounding the root of the lower second bicuspid, 
which is a devitalized tooth. The lesion extends way up to the cervical margin. 

Result of Operation: Aiter extraction of the tooth and curettage, the inflammation of the lymphatics 
decreased and finally disappeared. 

Patient: Mrs. P. C ^'>'"'^ i30. 

History: Patient had intermittent fever for three months. Temperature up to 100.5 F. Had been 
carefully examined for a cause without success. 

Roentgen Examination: Shows radiolucent area on lower first molar, indicating a blind alveolar 

Result of Operation: After extraction of the tooth, the patient's temperature remained normal. 


I'lGURE 120. 



Figure 121. 


Figure 123. 

Figure 124. 

Figure 125. 

Figure 126. 


Figure iii 

Figure 129. 

Figure 130. 


Roentgenology of Subacute Abscesses and Scar Bone 

Figure 131. 

Patient: Mrs. W. R. B. 

History: Upper first bicuspid had been devitalized and treated a long time ago. 
It occasionally felt sore and caused a slight swelling on the gum. When examined 
there was a large abscess formation under the mucous membrane of the hard palate, 
the swelling being about the size of a pigeon's egg. 

Roentgen Examination: A small radiolucent area is seen at the apex of the first 
biscupid, representing the amount of bone destroyed. The large swelling and accumu- 
lation of pus does not show in the picture, except that it is not very clear, because the 
film could not be held close to the teeth. 

Figure 132. 

Patient: Mrs. W. G. 

History: Patient had chills, temperature io2^F. Large swelhng on cheek and gum. 

Roentgen Examination: Shows radiolucent areas on the roots of the first molar 
and a large area over the second bicuspid, extending between the two teeth and indicating 
that a great deal of bone has been destroyed by the inflammatory process. 

Operative Findings: After extraction of the tooth, a great deal of pus escaped from 
the socket. 

Figure 133. 

Patient: Mr. C. F. 

History: Several years ago he had an acute abscess on the lower second bicuspid. 
The tooth was treated and filled. 

Roentgen Examination: Shows incomplete root canal filhng and a radiolucent 
area surrounding the root of the tooth. This is surrounded by a larger radiopaque 
area, which represents scar-bone that has filled in the place destroyed by the acute 

Figure 134. 

Patient: Mr. W. 

History: He had a very severe attack of acute abscess on the lower first molar 
many years ago. 

Roentgen Examination: Shows root canals partly filled and a radiolucent area 
indicating the part where there is still chronic inflammation tissue. The radiopaque 
area indicates that scar-bone has filled in the part which was destroyed. 


Figure 131. 

Figure 132. 

Figure 133. 

Figure 134. 


Roentgenology of Exostosis and Necrosis of the Tooth Roots 

Figures 135 and 136. 
Specimen: Extracted showing exostosis of the root ends, due to inflammatory 

Figures 137-139. 
Roentgen Examination: Show enlarged root ends in all three lower first molars, 
due to inflammatory processes. 

Figure 140. 

Patient: Mrs. W. L. W. 

Roentgen Examination: Shows irregular outline of roots of lower second molar. 
There is a radiolucent area surrounding the root. This indicates necrosis of the root 
end, caused by a chronic inflammatory condition. 

Figure 141. 
Patient: Mrs. T. M. G. 

Roentgen Examination: Shows irregular outline of mesial root of first molar, 
a condition which indicates absorption due to chronic inflammation. 

Figure 142. 
Patient: Mrs. H. G. B. 

Roentgen Examination: Granulomata at the ends of the roots of the first molar 
are indicated by the radiolucent areas. The mesial root shows marked exostosis. 

Figures 143 and 145. 
Roentgen Examination: Shows in Figure 143 absorption of the palatal root of 
the upper first molar and in Figure 145 absorption of the end of the lateral incisor. 

Figure 144. 

Patient: Mrs. I. O. H. 

History: Patient says she had periostitis 30 years ago in Norway. A piece of 
necrosed bone was removed by her dentist. Tooth is firm and reacts on the heat test. 

Roentgen Examination: Shows one root very much shortened. An irregular 
radiopaque area indicates scar bone and there is a radiolucent area at the distal side 
under the filling, which shows decay. 


Figure 135 

Figure 136. 


Figure 137. 


Figure 140. 

Figure 138. 

■* -^ % 

Figure 141. 


Figure 143. 

Figure 144. 

Figure 145. 


4. Diseases of the Marginal Part of the Periodontal Membrane 

Marginal Periodontitis or Pus Pockets are quite frequently found on 
single teeth and are due to infection of the marginal part of the periodontal 
membrane, with involvment and destruction of the bone which forms 
the alveolar socket. They are caused by injury or irritation such as come 
from poorly fitted gold crowns or fillings, from lack of contact between 
two teeth, causing food to crowd and stagnate in the interdental spaces, 
or from ligatures and rubber dam left around the neck of a tooth. In 
such cases the Roentgenogram shows a radiolucent area extending at the 
side of the tooth from the neck down into the tissue. 

Marginal Periodontitis Due to Impaction and Difficult Eruption. 
This has already been taken up in connection with impacted and unerupted 
teeth. After the gum has been pierced, food and fluids of the mouth 
have a free entrance between the gum and enamel and infection of these 
pockets occurs quite frequently. 

Pyorrhea Alveolaris. This condition, which is usually caused by 
systemic disturbances, starts with inflammation of the gums and later 
attacks the deeper tissues; namely, the periodontal membrane and the 
bone. It usually occurs on many or all of the teeth and the bacteria 
of the mouth start an infection which results in a persistent flow of pus 
from the alveolar sockets. The Roentgen method affords an excellent 
means of studying the progress of pyorrhea alveolaris, and is a valuable 
aid in diagnosis and prognosis of the disease, as it registers the extent 
to which the bone has been affected and destroyed. In early cases we 
see only an irregular outline of the bone edge between the teeth, the com- 
pact part of the bone having become destroyed and the remaining marginal 
part having a spongy appearance. Sometimes in the early stages the wall 
of the alveolar socket is affected, a dehcate, partial decalcification of the 
stratum durum being noticeable, extending along the alveolus and show- 
ing a wider space between the bone and tooth. More and more of the 
bone becomes absorbed, the process being more rapid on teeth which, 
on account of malocclusion or unequal occlusion, receive a great deal 
of movement in mastication. In cases of long standing, we find places 
where the entire wall of the alveolar socket has been destroyed, forming 
a funnel-shaped pocket around the tooth root. In molars the septa 


between the roots may also become affected, and the tooth, bemg finally 
only supported by the gum, becomes extremely loose. The cementum 
of the tooth gets soaked with pus and often covered with deposits of seru- 
mal calculus. Both factors contribute to the chronicity of the disease. 
The calcarious deposit is usually near the neck of the tooth and may 
be nodular or laid down in scales. It can be easily recognized in the 
Roentgenogram. Sometimes a Roentgen picture shows a very deep 
pocket almost reaching the apex, although the tooth may apparently 
be firm. This is undoubtedly due to the fact that the pocket is only on 
one side of the tooth, while on the other sides there is sufiicient bony 
attachment to hold the tooth firm. It also demonstrates that the Roent- 
gen picture shows principally the conditions on the mesial and distal 
sides of the teeth and only vague impressions of the buccal and Hngual 

Abscesses Due to Marginal Periodontitis. Alveolar abscesses may 
occur without the pulp being involved, due to closing up of the outlet of 
a pus pocket at the gingival margin. The pus then accumulates and 
causes a condition which, according to the symptoms, closely resembles 
an alveolar abscess due to a diseased pulp. The Roentgenogram is of 
inestimable value in recognizing such a condition. The abscess is found 
on the side of the root or between the roots of multi-rooted teeth and 
may occur both on normal and devitalized teeth. 

Large granulomata are sometimes formed between the roots of molars 
and, in the upper jaw, are often diflicult to diagnose by the Roentgen 
method, although they may be the cause of severe neuralgia. 

Abscesses may also come from infection of the apical tissue of a tooth 
if the pocket progresses to that extent. The pulp then becomes involved 
and may cause not only a severe apical abscess, but also pulpitis with all 
its well-known symptoms. 


Roentgenology of Marginal Periodontitis 

Figure 146. 

Specimen: Skull showing destruction of the marginal part of the alveolar process about an upper 
first bicuspid, probably due to lack of contact. 

Figure 147. 
Roentgen Examination: Shows a similar condition, but caused by an ill-fitting gold crown. Note 
the radiolucent areas on the mesial and distal sides of the first bicuspid, indicating destruction of the 

Figure 148. 

Patient: Miss L. 

History: Patient complained of occasional soreness of the gums. Had been in a run-down con- 
dition for a considerable length of time. 

Roentgen Examination: Shows on the right upper side, destruction of the alveolar process between 
the first and second bicuspids, second bicuspid and first molar and first and second molars, due princi- 
pally to fillings and ill-fitting crowns. There is also an indication of several apical abscesses and a 
frontal plate showed involvment of the maxillary sinus. 

Figure 149. 
Patient: Mr. N. 

History: No complaint except irritation of the gum around crown on lower incisor. 
Roentgen Examination: The increased radiolucency on the sides of the tooth indicates a pus pocket 
which has just reached the apex of the tooth, the pulp being still vital. 

Figure 150. 
Patient: Mr. S. 

History: Pus discharge around distal root of first molar. 

Roentgen Examination: Shows radiolucent area indicating pus pocket around distal root and 
extending between the roots of the first molar. 

Figure 151. 

Patient: Mrs. P. 

Roentgen Examination: Radiolucent area indicates pus pocket between the two bicuspids, caused 
by lack of contact of the filling in the first bicuspid. In the picture a temporary filling is shown which 
fills in the entire space. 

Figure 152. 
Patient: Mrs. K. 

Roentgen Examination: Shows bone destruction between cuspid and bicuspid due to lack of con- 
tact of the crowns of the two teeth. 

Figure 153. 

Patient: Mrs. H. E. D. 

History: No symptoms of discomfort or pain. Patient said tooth was devitalized and treated 
several years ago. 

Roentgen Examination: Shows large radiolucent area indicating pus pocket surrounding the 
root of the incisor. This pocket was evidently started by a perforation at the side of the tooth. 


Figure 14S. 

•• J 

^. / / 


Figure 149. 

Figure 150. 


Figure 152. 



Roentgenology of Pyorrhea Alveolaris 

Figure 154. 

Specimen: Dry skull. 

Photograph: Shows inflammatory destruction of the marginal part of 
the alveolar process, due to pyorrhea. The roots of the teeth show 
calcarious deposits. 

Figure 155. 

Specimen: Dry skull. 

Photograph: Shows pyorrhea condition further progressed, with de- 
struction of the alveolar process and inflammatory changes about the 
bone. The upper second bicuspid is especially involved. 

Figure 156. 

Specimen: Dry skull. 

Photograph: Here deep pockets are formed. There is loss of the 
interdental septum between the lower cuspid and bicuspid and the first 
bicuspid and molar. The outer plate of the alveolar process has been 
destroyed about the upper central incisor, lower. cuspid and first molar. 

Figure 157. 

Patient: Mrs. McC. 

Roentgen Examination: The Roentgen picture of the lower incisors 
shows inflammatory changes of the bone at the alveolar margin and cal- 
carious deposits around the necks of the teeth. 


Figure 154. 

Figure i: 

Figure i^6. 

Figure 157. 


Roentgenology of Pyorrhea Alveolaris 

Figures 158 and 159. 

Patient: Mrs. F. M. B. 

Roentgen Examination: In this case of pyorrhea there are no deep 
pockets, but the marginal part of the alveolar bone has been affected. 
Note the spongy irregular appearance of the marginal part of the bone 
between the teeth. In Figure 158 there is a deposit on the mesial surface 
of the second molar. In Figure 159 the irregular outline of the distal 
surface of the first molar shows that the cementum of the root has been 

Figures 160-163. 

Patient: Mrs. E. 

Roentgen Examination: Pyorrhea in this case has progressed much 
further. Deep pockets have formed, especially on the mesial sides of 
the first lower molars. Also in the upper jaw we find many large pockets, 
the left upper second molar having lost almost its entire bony support. 
Note that the left upper second bicuspid is a devitalized tooth and pre- 
sents a dark area which, on account of clinical symptoms, represents a 
blind abscess or granuloma. Note the absence of calcarious deposits. 

Figure 164. 

Patient: Mrs. D. C. P. 

Roentgen Examination: There are deep pockets between all the 
teeth. The bone presents a spongy appearance at its border. Note the 
large deposits on the root surfaces, which have the same degree of radio- 
pacity as the tooth. 


Figure 158. 

Figure 159. 

Figure 160. 

Figure 161. 

Figure 163. 

Figure 164. 


Roentgenology of Pyorrhea Alveolaris 

Figures 165-167. 

Pictures: Show lower incisors from three patients. 

Roentgen Examination: In Figure 165 the bone between the roots is very spongy 
and has been partly decalcified. In Figure 167, a great deal of the bone has been lost, 
the pockets extending almost to the apices of the teeth. In Figure 166 we find the 
teeth entirely surrounded by radiolucent tissue, the pulps having become devitalized 
and been removed in two incisors. This is indicated by the small radiopaque areas, 
which are temporary fillings closing an opening made into the root canals. The Roent- 
gen picture demonstrates how unreasonable it is to try to retain such teeth which show 
necrosis at the apex and are surrounded by diseased bone. 

Figures 168-171. 

Patient: Mr. G. T. S. 

History: Had completely broken down with rheumatic fever and suffered from 
intermittent attacks of conjunctivitis of the left eye for several years. Lost a great deal 
of weight and for several months had been unable to attend to his duties. His teeth 
were loose and discharged a great deal of pus. 

Roentgen Examination: Large pyorrhea pockets are shown on all the teeth. The 
left lower molar, as seen in Figure 171, shows entire destruction of the bone around the 
mesial root, including the interradicular septum and involving the pulp of the tooth. 

Result of Operation: After extraction of all the diseased teeth the patient improved 
rapidly and in seven weeks gained about 50 pounds. 

Figure 172. 

Patient: Mr. A. I. E. 

History: Patient had symptoms of acute abscess with swelling of gum over right 
upper cuspid. His dentist started to open the pulp chamber, but found the tooth 
sensitive. Slight inflammation of the gums about all the teeth. 

Roentgen Examination: Shows a radiolucent area on the mesial side of the tooth, 
not extending to the apex. A fine probe can be passed into this from the gum margin 
which, however, is very firm. We, therefore have to do with a pyorrhea abscess on a 
vital tooth. Note the radiopaque area in the crown of the tooth indicating the filling 
placed in the attempted opening to the pulp. 



Figure 165. Figure 166. Figure 167. 

Figure 168. Figure 169. Figure 170. 

Figure 171. Figure 172. 


5. Diseases of the Jaws 

Atrophy. Decrease in the size of the jaws may be due either to a 
pathological or physiological process. Tumors and cysts cause such a 
decrease as well as loss of teeth, which is usually followed by absorption 
of the alveolar process. If all the teeth are lost in old age, the entire 
alveolar process disappears. This may bring the mandibular canal 
and mental foramen close to the surface in the lower jaw and in the upper 
jaw sometimes there is only a thin wall of bone between the maxillary 
sinus and the mouth (see Figure 173). 

Fractures. Fractures occur more frequently in the lower than in the 
upper jaw because the maxillary bones are well protected by the zygomatic 
and nasal bones and below by the lower jaw. The Roentgen method is 
of great value in diagnosing the location and the nature of a fracture. 
It indicates whether it is simple, multiple or cominuted with the bone 
broken into small pieces and the teeth dislodged and driven into the 

Diffuse Osteomyelitis. If we consider the frequency of dental infec- 
tions involving the jaws, it is surprising how rarely we find a case of diffuse 
osteomyelitis. The disease occurs most frequently in the mandible and 
spreads rapidly in the cancellous part, involving the whole bone and caus- 
ing more or less necrosis. It is a serious disease and often a large number 
of sequestra are formed with occasional subperiosteal abscess formations. 
The teeth get very loose and the condition becomes either acute or chronic. 
The Roentgen ray is useful both for making an early diagnosis and for 
locating loose sequestra. The bone has a characteristic appearance in 
the picture, radiolucent channels indicating the infectious process and 
sequestra being easily recognized, especially if entirely separated from 
the bone. 

Ostitis. In ostitis, not only the cancellous part but the entire bone 
is affected. It may start from without (periostitis), or from within 
(osteomyelitis), but in either case the bone dies cell by cell. Suppurating 
ostitis may be distinguished by the dissolving of the bone into pus, while 
granulating ostitis is of a more chronic nature, only a little pus being 
formed and granulation tissue replacing the substance of the bone. Both 
suppurative and granulating ostitis show plainly a large amount of bone 


destruction in Roentgenograms, the destroyed part appearing ver\' radio- 

Necrosis. If bone dies in masses, the process is called necrosis of 
the jaw, which is caused by interference with the nutrition of a part for 
any length of time. It may be due to an inflammatory process destroy- 
ing the blood supply or to the misplacement and isolation from its source 
of nutrition of any part of the bone by fracture. We also find necrosis 
caused by toxic substances, such as mercun,- and phosphorus. After 
the bone has lost its metabolism and become a dead substance, nature 
makes an eflfort to exfoliate it. It is separated from the vital tissue by 
the action of osteoclasts, the separated dead part being called a sequestrum. 
Sequestra are obnoxious foreign bodies and cause continual irritation 
and suppuration. They are usually surrounded by inflammatorv- granu- 
lation tissue, but repair cannot take place unless they are removed. 
As a result of necrosis, a certain amount of caUous formation may occur 
to protect the weakened bone. This is usually formed in excess and 
■often causes considerable change in the contour of the part, but, as a 
rule, it is absorbed again later. 

Necrosed bone is recognizable in Roentgen pictures by its irregular 
and indistinct outline and is generally- surrounded by radiolucent areas 
representing the inflammator}' granulation tissue. To ascertain whether 
a sequestrum is entirely separated from the rest of the bone it is often 
necessary to take several pictures from different angles. 

Periodontal or Radicular Cysts. These are cysts of inflammator\', 
infectious origin and are usually formed by an epitheliated dental granu- 
loma. Epithelial remnants of the enamel organ, which are normally 
found in the periodontal membrane, have a tendency to proliferate when 
stimulated by chronic inflammation and are apt to grow over the inside 
■surface of the granuloma. Exudates accumulate in the lumen and as they 
increase the cyst grows, at the expense of the bone. A Roentgenogram 
wiU indicate a cyst clearly, showing a large radiolucent area, usually at the 
€nd of a tooth which is devitalized or has a diseased pulp sticking into it. 

Periodontal cysts are sometimes found not connected with a tooth 
root, but in such cases the guilty tooth may have been extracted, the 
cyst having escaped notice, or there may have been a granuloma at the 
time of extraction, which, not having been removed, later grew into a 
cyst (see Figure 193). 


In the upper jaw a periodontal cyst may grow into the maxillary 
sinus, sometimes filling it almost completely. Such a condition is diffi- 
cult to diagnose. 

Multilocular cysts start in a similar manner. They may originate either 
from the formation of several cysts in one granuloma, from the formation 
of a "cyst from more than one tooth, or from the development of cysts in 
various medullary spaces of the cancellated part of the bone, the fluid 
accumulating and extending them, leaving bone lamellae in between 
(see Figure 192). 

Follicular or Dentigerous Cysts. This type of cyst, which occurs 
rather rarely, is caused by the tooth follicle of an unerupted, impacted, 
supernumerous or misplaced tooth or tooth germ. It may contain one 
or many well formed teeth or rudimentary tooth masses, or it may be 
formed from the enamel organ without a tooth having been developed. 
Like the periodontal cysts, they grow at the expense of the bone, but much 
more slowly. We can discern them readily in a Roentgen picture on ac- 
count of their radio] ucent appearance and the radiopacity of the mis- 
placed teeth (see P'igure 190). 

Tumors. For tumors the Roentgenogram is only of value in cases 
which produce bone or in which bone substance is affected and degener- 
ated, though it is also helpful in differentiating the latter from the more 
superficial varieties in order to determine the mode of operation. 

Osteoma. These are benign tumors and of very slow growth. They 
are very frequently found in the jaw, especially on the lingual surface of 
the mandible and the palatal surface of the maxilla. The tumor usually 
consists of very dense cortical bone and is, therefore, extremely radio- 
paque, showing as a very light, well defined area on the Roentgen picture. 

Osteosarcoma. Osteosarcomata are the most frequent tumors of 
the bone. They grow in the bone from its connective tissue cells, as well 
as from bone-forming cells. When they grow in the cancellous part^ 
they distend and destroy the bone. This condition can be recognized 
in the Roentgenogram and difi'erentiated from the fibrosarcoma. When 
they grow from osteoblasts of the periosteum, the new trabeculae of bone 
can be seen extending mostly at right angles to the surface. 

Carcinoma. This is a malignant, epithelial tumor which infiltrates and 
may give rise to metastasis. It has a tendency to invade the lymph 
spaces, growing into the lymph vessels and giving rise to metastasis 


along the paths of absorption. A carcinoma does not occur primarily 
in the jaws, but bone may be secondarily affected by its destructive 
nature. Fatty degeneration may also occur, due to impaired metabolism, 
and necrosis of the soft and hard tissues is often the result of local inter- 
ference with the circulation. These changes, when they affect the maxil- 
lary or mandibular bones, can be easily distinguished in a Roentgenogram. 


Roentgenology of Atrophy of the Jaws 

Figure 173. 

Patient: Miss E. 0. B. 

History: Patient suffered from trifacial neuralgia on left side, espe- 
cially referred to lower jaw and lip. 

Roentgen Examination: A sharp spur is found in the incisor region, 
the alveolar process and part of the mandible having been atrophied. 

Result of Operation: The pain was relieved by anesthetizing the left 
inferior alveolar nerve. Removal of the spur gave no relief. Neurec- 
tomy of the left inferior alveolar nerve was performed by Dr. Mixter 
and relieved the neuralgia. 




Roentgenology of Fractures of the Jaws 

Figure 174. 
Patient: Miss L. D. 

Roentgen Examination: Shows position of the fragments after fixation 
of the teeth. 


Figure 174. 


Roentgenology of Fractures of the Jaws 

Figure 175. 

Patient: Mr. R. C. P. 

History: Patient fractured jaw eight weeks previous to having the 
Roentgen picture taken. The teeth opened and closed fairly well, but 
the side movement was not so good, the forward movement being very 

Roentgen Examination: Shows fracture at the neck of the condyle 
and overlapping of the two fragments. 


"ll ^1 



Roentgenology of Diffuse Osteomyelitis 

Figures 176 a7id 178. 

Patient: Mrs. A. L. 

History: Patient had a gold crown put on a tooth by her dentist on 
Dec. 24, 1915. Dec. 26, the tooth was extracted by another dentist, 
on account of an abscess condition. Dec. 28 she went to a hospital 
and received palliative treatment. Jan. 8, 1916, she was sent to the 
author for examination. She complained of pain in the lower jaw, inabihty 
to open her mouth and soreness of the lower teeth. Temperature, 99.5 F. 

Examination: In the lower jaw, the following teeth were present: 
the left lower molar and the bicuspids, cuspids and incisors on both sides. 
These teeth and both right lower bicuspids were extremely loose and 
there was evidence of the recent extraction of the right lower first molar. 
The upper teeth were firm and, apparently, in good condition. Two 
Wassermann tests were negative. 

Roentgen Examination: A large radiolucent area was found beneath 
the socket of the extracted right lower molar (see Figure 176). From 
this place to the bicuspids of the other side, the entire body of the mandible 
showed radiolucent areas and channels, indicating an osteomyelitic 
condition (see Figures 176 and 177). The same condition was found in 
the alveolar process, the front part of which is shown in Figure 178. 


Figure 176. 

Figure 177. 


Operative Findings: On Jan. 20, 1916, all the loose teeth in the 
lower jaw were extracted and the entire cancellous part between the 
cortical plates was curreted. Many small sequestra were found and 
removed. The wound healed rapidly, but two more pieces of bone 
were expelled later. March 2 the patient returned with swelling and 
pain on the left side. Another Wassermann test was again negative 
and a new Roentgenogram showed that healing had taken place on the 
right side/but that the process of disease had involved the left side exten- 
sively (see Figure 179). An operation was performed on this side March 
3 and from that time on the healing continued normally. September 8 
two more sequestra became evident. One was removed from the mouth 
and the other from the submental region and the wounds healed by 
first intention. November 25 an abscess seemed to point at the angle 
of the jaw, where there was also considerable callous formation. The 
place was explored and a small sequestrum removed, but the sinus con- 
tinued to discharge. A later Roentgenogram showed a normal condition 
everywhere except at the left angle of the jaw, where another small 
sequestrum was found in the middle of the bone. This was removed 
January 31, the sinus excised and the wound closed. The wound healed 
by first intention. The hard swelling disappeared gradually, so that the 
outline of the face was again normal. 


Figure 178. 

Figure 179. 


Roentgenology of Ostitis and Negrosis of the Jaws 

Figure i8o. 

Patient: Mr. W. C. B. 

Roentgen Examination: Shows large radiolucent area with indefinite outline, into 
which protrudes the root of the lateral incisor. 

Operative Findings: A large cavity filled with granulation tissue and pus was 
found, the surrounding bone being of spongy character. 

Figure i8i. 

Patient: Miss C. F. M. 

History: Patient was suffering from infectious arthritis, most of the joints being 
involved and painful. She says that eight years ago an abscess was opened and scraped. 
The condition then became quiescent, but after two or three years a sinus formed on 
the gum, from which more or less pus has been discharged ever since, with occasional 
subacute attacks. 

Roentgen Examination: Shows very large radiolucent area with well-defined 
outUne, apparently starting from the devitalized lateral incisor. 

Operative Fi)idings: The bone cavity was filled with inflammatory granulation 
tissue, the walls being formed by cortical bone of good appearance. 

Figure 182. 

Patient: Mr. W. 

History: The patient had a swelling of the gum over the lateral incisor several 
times with discharge of pus from a sinus. 

Roentgen Examination: Shows a large radiolucent area originating around the 
devitalized lateral incisor. 

Figure 183. 

Patient: Mr. I. M. B. 

History: Lateral incisor had been devitalized for a long time, discharging occasion- 
ally through a sinus, but without causing any disturbance. 

Roentgen Examination: Shows large radiolucent area of irregular and undefined 
outline, the root apex being necrosed. 

N| Operative Findings: The bone cavity was filled with granulation tissue, which was 
found to contain colonies of actinomyces. 

Figure 184. 

Patient: Mrs. W. P. L. 

History: The right upper bicuspid had been extracted ten days before the picture 
was taken and in that time a growth formed from the wound, being very sensitive 
and bleeding easily. 

Roentgen Examination: Shows two small radiopaque objects in the socket. It 
also shows the outline of the growth, which is more radiopaque than the other soft 

Operative Findings: Cleaning out of the socket resulted in the discovery of two 
small sequestra, probably pieces of the alveolar process which had been fractured off. 
The growth was made up of granulation tissue. 


Figure iSo. 

Figure 181 

Figure 1S2. 

P^IGURE 183. 

Figure 184. 


Roentgenology of Necrosis of the Jaw 

Figures 185 and 186. 

Patient: Miss A. W. 

History: Gum had been inflamed in front of upper jaw for a long time 
and was discharging pus from a sinus. 

Roentgen Examination: A radiopaque object which, from its outline, 
may be taken for a front tooth is shown in the picture. In Figure 185 
the soft tissues of the nose appear in the lower part. In Figure 186 the 
condition of the maxillary bone is shown and from the irregular, shaggy 
appearance we conclude that an extensive area is necrosed. 





Roentgenology of Dentigerous Cysts 

Figures 187 and 188. 

Patient: Mrs. H. H. P. 

History: Upper cuspid has never erupted. The lateral incisor has 
been sore at times. 

Roentgen Examination: Shows a radiopaque object which seems to 
be the missing tooth. Its cusp is in contact with the lateral incisor. 
Its root seems to extend into a radiolucent area of definite outline, which 
is probably a c^^st. 

Operative Findings: After extirpation of the tooth, a brownish liquid 
escaped from the wound. This was found to come from a cavity lined 
by a membrane. From this cyst cavity another opening was found, 
probably made accidently during the operation. This led into the maxil- 
lary sinus. Washing out of the sinus proved it to be in normal condition. 



Figure 187. 

Figure 188. 


Roentgenology of Dentigerous Cysts 

Figure 189. 

Patient: Mr. Si. 

History: Complained of iDad-smelling fluid escaping from a sinus behind the lower 
second molar. 

Roentgen Examination: An intraoral film showed a very radiolucent area behind 
the last erupted molar, but no impacted tooth could be discovered. An extraoral. 
plate was then taken, which showed a large radiolucent area surrounded by a light line. 
This is the typcal appearance of a cyst and it was found to contain the missing wisdom 
tooth at the lower border of the mandible. 

Figure 190. 

Patient: Boy, 15 years old. Courtesy of Dr. Halsy B. Loder. 

History: First seen in September, 191 5, when he had a swelling of the right side 
of the face. This was confined to the ascending ramus of the jaw. The gradual swelling 
had been noticed for nine months and was attributed to a blow. There had been 
slight pain. 

Roentgen Examination: Courtesy of Dr. A. W. George. Shows a large dentig- 
erous cyst, containing one well-formed tooth and a number of smaller foreign bodies, 
which have about the same radiopacity as the tooth. 

Operative Findings: After exposing the ascending ramus of the jaw, which was 
hardly thicker than egg-shell, an area of this was removed and the cyst was dissected 
free from the bone. The cyst, itself, was thin-walled in its upper part and nearly | inch 
thick in its lower part. In the course of the separation it was ruptured, and straw 
colored fluid escaped. This was removed, leaving a smooth-walled cavity in the bone. 

Result of Operation: A Roentgenogram taken two months later showed that 
all foreign bodies had been removed. 

Pathological Examination: Shows a cyst sac lined with epithelium and containing 
an adamantenoma. 


Figure 190. 


Roentgenology of Simple and Multilocular Periodontal Cysts 

Figure 191. 

Patient: Mr. J. T. G. 

History: Patient complained of tender place on outside of face which he noticed 
especially when shaving. 

Roentgen Examination: Shows a large radiolucent area with well-defined outline. 
The lower first bicuspid is devitalized and is probably the cause of the cyst. Below the 
root apex of the second bicuspid note the picture of a smaller area, which is still more 

Operative Findings: The cavity was filled with pus, containing cholesterin and 
Uned by a membrane which was covered by epithelium. The cyst was located between 
the two bone plates, in the outer one of which there was a perforation, showing in the 
Roentgen picture as the smaller dark area under the second bicuspid. This is the place 
where the patient felt the tenderness. 

Figure 192. 

Patient: Miss E. R., courtesy of Dr. H. H. Germain. 

History: Had swelling on lower jaw for several months (outer surface). Teeth 
had been treated without relief. 

Roentgen Examination: Roentgen plate by courtesy of Dr. A. W. George. In 
the region of the mental foramen the mandible seems to contain several radiolucent 
places. These are separated by lamellae of bone. The second bicuspid is apparently 
a vital tooth. From its apex the most prominent vertical septum starts and on each 
side of it there is a dark area indicating a cystic compartment. These may have been 
caused by granulomata on the roots of the first bicuspid and first molar, which had 
previously been extracted. The cuspid is also devitalized and seems to extend into the 

Operative Findings: Cyst cavities filled with pus and granulation tissue. 


Figure 191. 

Figure 192 


Roentgenology of Periodontal Cysts 

Figure 193. 

Patient: Mr. J. C. F., courtesy of Dr. E. A. Locke, who referred the patient to the author. 

History: Patient was unusuaUy well until about a year before he was referred for e.xamination 
of the mouth, when he broke down after a severe attack of grippe, the symptoms being principally 
those of nervous collapse. He was in the South for two months and then returned to work. Has 
been examined at Johns Hopkins University. Was obliged to give up work again and spend about 
six months in the mountains. While there he had some palpitation and dyspnoea and was evidently 
very anaemic. For some years he suffered from hemorrhoids and on Aug. 17, 1916, was operated on by 
Dr. T. Chittendon Hill. At this time the blood examination was as follows: 

Haemoglobin 70% 

Leucocytes 10,000 

Red count 3,000,000 

A smear showed a slight degree of achromia. On Aug. 28, the blood count was: 

Haemogloblin 85% 

Leucocytes 6,000 

Red count 5,300,000 

On September 18, 1916, the blood count was as follows: 

Haemoglobin 85% 

Leucocytes 7,000 

Red count 5,120,000 

The patient at this time had recovered from'the operation entirely and seemed in much better health. 
The white count, however, seems to have increased again and the red count to have decreased. A 
Roentgen examination by Dr. George on Sept. 18 showed a large periodontal cyst of the jaw and abscesses 
about the roots of two more teeth. About 16 years ago the patient had an acute abscess on the left 
lower first molar, which had to be extracted. 

Roentgen Examination: Shows a large radiolucent area in the mandible, all the teeth of this side 
being vital. A radiopaque object is seen in the middle of the cyst. 

Operative Findings: After opening into the cyst, pus which was apparently under pressure escaped 
at once. The bone cavity was lined by the usual cyst sac and contained the apex of the first molar. 
It was evidently caused by the abscess which had occurred years before. 

Result of Operation: The operation was performed by the author on Oct. 4, 1916, and on Oct. 
II, 1916, Dr. Locke's report showed the following blood count. 

Haemoglobin 92% 

Red count 5,500,000 

The patient was seen again eight months later, when he reported that he has been perfectly well ever since. 

Figure 194. 

Patient: Miss C. B. G. 

History: Had suffered dull pain in lower jaw for seven years and complained of numbness in left 
side of lower lip and bad taste in mouth. Had a Roentgen examination at the Forsyth Dental Infirmary, 
but no cause was found. 

Roentgen Examination: Shows a large radiolucent area in the ramus, surrounded by a light line. 
A very dark area is seen in the region of the post molar triangle. 

Operative Findings: Opening of the cyst from the post molar triangle revealed a perforation of the 
bone, which appears in the Roentgen picture as a very dark area about the size of a pea. The bone 
over the post molar triangle was cut away and revealed a large cyst of the dimensions shown in the 
picture. The cyst sac communicated with the socket of the wisdom tooth and contained a great deal of 
pus and cholesterin. 


Figure 193. 

Figure 194. 


Roentgenology of Periodontal Cysts 

Figure 195. 

Patient: Miss A. H. P. 

History: Patient complained of poor health and was referred by her 
dentist for extraction of the left upper molars. During the extraction 
the antrum was opened into and a frontal Roentgen plate was taken im- 
mediately to ascertain the condition of the sinuses. 

Roentgen Examination: On the left side the picture shows a radio- 
paque antrum, on the right side a radiopaque structure of definite shape 
with a well defined outline. The upper part of the antrum on this side 
is normal. 

Operative Findings: The right maxillary sinus was found to be filled 
by a periodontal cyst, originating from abscessed teeth in the upper jaw. 
After the cyst membrane was removed the bone cavity was found to be 
whole and to contain no outlet into the nose. The left sinus was filled 
with polypoid growth. 


Figure 195 


Roentgenology of Multilocular Cysts 

Figures 196 and 197. 

Patient: Mr. R. W., age 19 years. Courtesy of Dr. Samuel Mixter 
and Dr. G. D. Cutler. 

History: When one year of age was hit hard on jaw with pump handle 
and was said to have fractured jaw at that time. Since then slow, con- 
tinuous, painless growth went on, but the tumor was the present size 
ever since he could remember. About five weeks before being referred 
to Dr. Mixter he received an injury from a piece of ice striking his chin. 
One week later had pain and abscess formation, which broke and dis- 
charged foul pus and some blood, the discharge continuing through the 
sinus until the time of the present examination. 

Examination: Well developed young man. Large, hard, irregular 
tumor found on lower jaw, mostly on right side, so firmly attached as 
to be continuous with the jaw bone. Skin of tumor not adherent, abnor- 
mal nor tender except at right corner of mouth, which was the site of the 

Roentgen Examination: Roentgen plate by courtesy of Dr. L. B. 
Morison. Figures 196 and 197 are pictures taken at different angles. 
Note the large cyst cavities and their relation to the decayed teeth. 


Figure 197. 


Roentgenology of Carcinomata of the Jaws 

Figure 198. 

Patient: Courtesy of Dr. L. B. Morison. 

History: The tumor started as an epithehoma of the Up. The 
metastatic processes of the carcinoma affected the jaw, as seen in the 
Roentgen picture. 

Roentgen Examination: Plate by courtesy of Dr. L. B. Morison. 
The picture shows destruction of a large part of the mandible. Note 
the increase in the radiability of the part where the bone has been de- 
stroyed by the tumor. 





Figure 198. 


6. Diseases of the Air Sinuses 

The accessory air sinuses of the nose are usually divided into an ante- 
rior group, made up of the frontal, ethmoidal and maxillary sinuses, which 
open into the middle meatus, and a posterior group, the posterior eth- 
moidal cells and the sphenoidal sinuses opening into the superior meatus 
of the nose. The inflammatory infections of all sinuses have features 
in common and frequently one becomes infected from the other. Dis- 
eased conditions can be diagnosed by means of the Roentgen ray. 

Maxillary Sinusitis. Maxillary sinusitis in its acute suppurative or 
chronic form occurs much more frequently than is supposed. Evidence 
of sinus disease has been found in from thirty to fifty per cent of cases 
under post mortem observation.^ While patients seek relief from the 
discharge of pus and other symptoms of acute inflammation, the chronic 
disease which manifests itself more indirectly by symptoms in the neigh- 
boring regions, the nose, pharynx, eyes, ears, teeth, head and face, or by 
interference with the general health, loss of weight, toxemia, mental 
depression, arthritis, or by other focal infections, is quite frequently 

Maxillary sinusitis may be caused from infections of either the nose 
or the teeth. According to Brophy, about seventy-five per cent of the 
cases are due to dental infection and usually they follow the occurrence 
of alveolar abscesses on the teeth which are related to the sinuses. 

Roentgenographic examination is undoubtedly helpful in making a 
diagnosis of such conditions, but it should not be relied upon entirely. 
It is not easy to distinguish between acute and chronic maxillary sinusitis 
by means of the Roentgen method. An antrum filled with pus and affected 
by chronic inflammatory changes of the mucous membrane, with or with- 
out the formation of polypi, is less radiolucent and, therefore, has in a 
frontal plate a cloudy and lighter appearance than the healthy side. 
A lateral view shows the extent of the sinus and frequently also the 
neighboring teeth, but intraoral films give a clearer picture and will 
establish more definitely the dental cause, if present. They are, however, 

1 Harke, E. Fraenkel, Lappelle and ]\Iartin, quoted by F. Martin, De la Frequence de rEmpyeme, 
Bordeau, France, igoo. 


of no value in diagnosing the condition of the antrum. When diseased 
antra are discovered one should always take films of the maxillary bicus- 
pids and molars and, vice versa, when there are abscesses on those teeth 
which come close to the antra, the patient should be advised to have 
the sinuses Roentgenographed and transilluminated. 


Roentgenology of Maxillary Sinusitis 

Figures 199 and 200. 

Patient: Mr. W. W. C. 

History: Pain in zygomatic and infraorbital regions and discharge 
from right nostril. A frontal Roentgen plate shows radiopacity of the 
right antrum. The cause was ascertained by a film which showed radio- 
lucent areas on two roots of the upper first molar, indicating abscesses. 

Operative Findings: The antrum was found to be filled with polypoid 
growth and the bone over the molar was entirely necrosed. 


Figure 199. 

Figure 200. 


Roentgenology of Teeth as Etiological Factors in Maxillary Sinusitis 

Patient: Miss G. W. Figure 201. 

History: Complains of bad taste in naso-pharynx, but no pain whatever. 

Roentgen Examination: Intraoral films show many teeth with evidences of root canal work and 
radiolucent areas indicating abscesses extending to the maxillary sinus. A frontal plate shows radio- 
pacity of the right antrum. 

Operative Findings: Large necrosed areas in the upper jaw and the mucous membrane of the 
antrum covered with granulations. 

Patient: Miss A. P. Fk"re 202. 

History: Patient was in poor health and was referred by her dentist for extraction of the left upper 
molar. After extraction of the tooth a probe could be passed into the antrum, which was found to con- 
tain granulation tissue. 

Roentgen Examination: The previously taken film showed a large radiolucent area on the root of 
the upper first molar, all three molars being devitalized. A frontal plate taken immediately after the 
extraction showed radiopacity of the left maxillary sinus and a cyst of the right sinus, described under 
Figure 195. 

Patient: Mrs. R. H. Pm<re 203. 

History: Patient complained of neuralgic pain on right side of face. 

Roentgen Examination: Shows right upper second bicuspid and molar devitalized. These teeth 
are in close relation with the antrum. 

Operative Findings: After the molar was extracted, a small amount of pus came from the antrum. 

Patient: Miss F. E. M. F'iure 204. 

History: Patient had been feeling very badly for several months. 

Roentgen Examination: Shows right upper third molar devitalized. Both molars enter into the 
maxillary sinus for quite a distance. A frontal plate showed radiopacity of the right antrum. 

Patient: Mrs. F. K. P^&ure 205. 

History: Complained of severe pain in head. 

Roentgen Examination: Pilms of the teeth show several abscesses. The one on the palatal root 
of the first molar made involvment of the maxillary sinus seem possible. A frontal plate showed a 
radiopaque area in the lower part of the sinus. 

Operative Findings: Upon opening the sinus, an abscess was found on the floor of the antrum 
over the region of the first molar. 

Patient: Miss M. L. Figure 206. 

History: Patient had been in a run-down condition for a considerable length of time. Had been 
under a physician's care, but did not improve. 

Roentgen Examination: Shows indications of many pus pockets and abscesses in the right upper 
jaw. A frontal plate showed that the antrum was involved. 

Result of Operation: After removing the teeth and treating the antrum, the patient improved 

Patient: Mrs. A. H. P'S^'re 207. 

Roentgen Examination: A film shows a radiolucent area around the roots of the upper first molar, 
which is fractured. Involvment of the antrum was suspected and ascertained by a frontal plate. 

Patient: Mrs. H. K. Figure 208. 

Roentgen Examination: Routine Roentgen examination shows many diseased roots in the upper 
jaw and radiopacity of the maxillary sinus. 

Patient: Mr. D. G. Fig'"-e 209. 

History: Five weeks before being referred to the author the patient began to have rheumatic 
swellings and pains in the knees. The shoulders were next attacked and in a short time all the large 
joints became involved. He took electric baths, but without success. When he came for examination 
of the mouth, he was walking with crutches and was in great pain, although he had no pain whate\'er 
in the face or mouth. 

Roentgen Examination: Shows radiolucent areas indicating abscesses on an uppef incisor and upper 
molar. The antrum was suspected and proved to be radiopaque. 

Operative Findings: The antrum was opened and found to contain inflammatory granulation tissue, 
caused by the tooth which was extracted. 

Result of Operation: Patient first suffered exacerbation due to the surgical autoinnoculation and 
had to stay in bed for a few days, not being able to use his joints. He then started to improve and 
after seven weeks was entirely rid of all his arthritic symptoms. 

Patient: Mr. D. Fisure 210. 

History: During extraction of the first molar, which had been devitalized for a long time and, 
therefore, was very brittle, the palatal root was pressed into the maxillary sinus. 
Roentgen Examination: Shows its position and thus aids its removal. 


Figure 201. 

Figure 202. Figure 203. Figure 204. 


Figure 205. Figure 206. Figure 207. 

Figure 208. Figure 209. Figure 210. 


7. Salivary Calculi 

Calculi are most commonly found in the sublingual and submaxillary 
glands and ducts and are of rather rare occurrence in the parotid gland. 
It is not yet entirely settled whether the calculi are formed secondary 
to infection, calcium phosphate and carbonate being deposited concentri- 
cally around emboli, leucocytes or organic exudates, or whether the infec- 
tion which usually accompanies such cases is due to the irritating presence 
of the calculi. A Roentgenogram of the inflamed or swollen floor of the 
mouth will not only show up the presence of a suspected calculus, but wiU 
also give some idea as to its location. The large intraoral film is the best 
one to use and should be placed between the teeth as far back as possible. 
The patient's head should be bent at an extreme backward angle so that 
the ray can be directed from the submandibular region on the film. If 
the calculus is in the submaxillary gland itself or in the parotid gland, 
an extraoral plate will give the most accurate information. 

Roentgenology of Salivary Calculi 

Figure 211. 

Patient: Mrs. C. A. P. 

History: Patient complained of swelling under the tongue which varied in size 
and was usually largest before meal times. 

Roentgen Examination: Shows a radiopaque object on the right side of the floor 
of the mouth opposite the first molar. 

Operative Findings: An incision was made in the mucous membrane of the floor 
of the mouth to expose the submaxillary duct and sublingual gland. The duct did not 
contain any foreign material, but the sublingual gland contained a salivary calculus 
surrounded by a small amount of pus. 


Figure 21 


Roentgenology of Salivary Calculi 

Figures 212 and 213. 

Patient: Mrs. H. E. M., courtesy of Dr. John T. Bottomley. 

History: Patient had tumor-like swelling on cheek and felt a hard 
substance under the skin, but no pain. 

Roentgen Examination: Plates by courtesy of Dr. A. W. George. 
Two plates had to be taken to ascertain the location of the foreign bodies. 
From the lateral view, shown in Figure 212, one might think the radio- 
paque foreign bodies were located in the maxillary sinus, but the second 
plate shows that they are outside of the maxillary bone and from the 
location in both plates, we may conclude that they are in the parotid 

Operative Findings: The foreign bodies, after being removed, were 
found to be small lumps and felt like cartilage. Pathological examination 
showed them to be organized thrombi, which had become calcified. These 
phleboliths showed concentric arrangement. 



Figure 212. 

Figure ji : 





WHILE the Roentgen ray is of inestimable value in the diagnosis 
of abnormal and diseased conditions, it is almost indispensable 
as an aid in certain therapeutic processes such as root canal work, apico- 
ectomy, the setting of fractured jaws, etc. It is a great help to have a 
Roentgenogram before any treatment is started, as a correct diagnosis 
is the first step in determining the necessary therapeutic method and 
often saves the patient a great deal of time and annoyance. The progress 
of treatment can be followed step by step and the final result of mechanical 
procedures can thus be ascertained. To follow the process of healing is 
not only of interest to all concerned, but is of great scientific value for 
reports and for showing the success of newly developed methods and 
surgical procedures. 

1. The Treatment of Root Canals 

Root canal treatment and filling has been the greatest short coming 
in dentistry-, principally because without a Roentgenogram the dentist 
works in the dark, trying to treat a condition which has not been prop- 
erly diagnosed. If we know the proper size, length and direction of the 
root canals and their abnormal conditions, we can more easily accomplish 
the desired result. Poor root canal fillings are found in the mouths of 
almost every patient (see Figures 214-222). 

Prognostic Roentgen Examination before Removing Pulps from Vital 
Teeth. Our knowledge of the etiology and complications of alveolar 
abscesses and realization of the uncertainty of root canal fillings should 
impress on our minds the seriousness of pulp extirpation. He who 
extirpates the pulp of one or more teeth to restore masticating efficiency 
by bridge work renders poor service if blind abscesses develop on the de- 


vitalized teeth, endangering the patient's health. A pulp should not 
be sacrificed except after most careful consideration and prognostic study 
of the roots and root canals by means of Roentgenograms. The Roent- 
gen picture may show normal canals, open apical foramina, accessory 
foramina, bent and curved roots, canals made inaccessible by secondary 
dentine, and pulp stones (see Figures 92-98). 

Prognostic Roentgen Examination of Previously Treated Pulps and 
Pulps which are to be Treated. It is of great importance to make sure 
of the probable outcome before involving the patient in lengthy root canal 
treatment and before using devitalized teeth as abutments for expensive 
prosthetic appliances. If the Roentgenogram shows no extensive involv- 
ment of the periapical tissue, the condition can usually be kept within 
normal bounds if the root canal is treated and filled to the apex. Small 
blind abscesses or granulomata of short duration will disappear after 
ionic medication, but if broken root canal instruments are discovered, 
if there is indication of extensive bone destruction due to an abscess or 
granuloma, if the apex is found to be necrosed, or if the side of the root 
has been perforated, the tooth, as a rule, cannot be restored to normal 
by root canal treatment alone. It should either be extracted or receive 
surgical treatment directed towards the periapical disease, the operation 
being called apicoectomy or root amputation. 

The Use of the Roentgen Ray as a Guide in Root Canal Cleaning 
and Filling. The importance of the removal of every particle of pulp 
tissue, whether healthy or diseased, from the canal or canals of a tooth 
has only recently been fully realized. It is also imperative for the canal 
to be properly reamed and enlarged, either by mechanical or chemical 
means, and for the apical foramina to be hermetically sealed by means 
of suitable root canal fillings. The only safe way to determine whether 
a canal is properly prepared for successful filling is by means of the 
Roentgen ray. If the operator has a Roentgen machine by his 
chair, he can insert broaches of the right size and take a picture 
with a rubber dam in place. The rubber dam clamps, however, 
should be removed and replaced by ligatures so as not to confuse the 
picture. If the film is to be taken at some future time or in a different 
place, fine wires with looped ends and containing the antiseptic dressing 
should be inserted into the canals, after which the cavity should be 
sealed. This process ought to be repeated until the Roentgen picture 


shows that the wire extends to the very end of the root. After the root 
canal is filled, another Roentgenogram should be taken and, in case the 
filling does not reach the apex of the root, or each of the roots, it should 
be removed and replaced by a perfect one (see Figures 233-250). 

2. Apicoectomy 

Prognostic Roentgen Examination. Before undertaking apicoectomy 
on a tooth, the condition should be carefully studied. Observe the 
shape of the root and the extent of the abscess towards the cervical mar- 
gin. If too much of the root has to be excised, there will not be enough 
alveolar process left to hold it firmly after the operation. A tooth with 
pyorrhea or marginal pus pockets is for the same reason not a favorable 
case. Neither should a tooth be operated on if there is another abscess 
close to it, as this would directly or indirectly reinfect the healing tissue. 

Checking Up of the Different Steps. Proper root canal treatment is 
the first step in apicoectomy. The operation can only be successful 
if future infection is prevented by sterilization of the root canal and 
dentinal tubules. Roentgenograms are used in the manner described 
for root canal treatment to check up the different steps. The final 
one, showing the extent of the root canal filling, gives us also an idea 
of the length of the root, the position of the neighboring teeth and the 
extent of the abscess. 

Following Up the Healing Process. The author takes a Roentgen 
picture immediately after the operating, to make sure of the result of the 
operation. Successive pictures, taken every six months, show the filling 
in of bone tissue, the process usually being completed in from one to two 
years, according to the size of the bone cavity and the age of the patient. 

3. Prosthetic Dentistry and Orthodontia 

Conditions of Roots Used for Prosthetic Abutments. It has already 
been pointed out that it is well to Roentgenograph a tooth or root before 
considering its use as an abutment. Much time and annoyance may be 
saved by finding out whether the periapical tissue is involved, whether 
the root end is healthy or necrosed and whether the canals can be properly 
treated and filled. It is not sufficient to be contented if a tooth is strong 
and firm or if it gives no discomfort. Neither is it justifiable to nurse 
along diseased roots, simply because they are the means of supplying 


and attaching profitable crown and bridge work. The patient's health 
should not be jeopardized for the sake of convenience or appearance. 
To-day it is the moral duty of every dentist to make sure, by means 
of the Roentgen ray, that a devitalized tooth is healthy and surrounded 
by healthy bone before he makes use of it for a bridge abutment (see 
Figures 223-227). 

Unerupted Teeth and Broken-off Roots. If a tooth which has 
never erupted is to be replaced, the first thing to be decided is whether 
it is concealed somewhere in the jaw as an unerupted, impacted tooth. 
Frequently unerupted teeth start growing if stimulated by the pressure 
of prosthetic appliances. The author once saw a case where an unerupted 
cuspid pushed the Richmond crown of a bridge from the root. If the 
gum has an inflamed or suspicious appearance, a Roentgen picture should 
be taken to find out if there are broken-off roots irritating the tissue (see 
Figures 288-294). 

Orthodontic Treatment of Unerupted or Partially Impacted Teeth. 
Cuspids are frequently found in a position from which they cannot right 
themselves, but by orthodontic means they can be slowly pulled into 
place. Roentgen pictures serve as a means of finding out whether the tooth 
is hopelessly impacted and has to be removed, or whether there is a chance 
of getting it into position after the bone and soft tissue have been cleared 
out of the way by surgical means (see Figures 297-301). 

4. Treatment of Fractured Jaws 

The locating of fractures by means of the Roentgen method has 
already been described. Although we can very often judge the result of 
setting the bones by the occlusion of the teeth, it is always well to take 
a Roentgenogram and make sure that the best result has been accompHshed. 
If the healing does not progress as expected in a compound fracture, one 
can often locate, by means of the Roentgen method, sequestra or parts 
of^teeth M^hich have been lost in the wound. 

5. The Healing of the Jaws after Operative Interference 

The Removal of Foreign Bodies and Odontomata. If foreign bodies 
are located in a jaw or odontomata found by the Roentgen method, it 
is always well to take another Roentgen plate after the operation to ascer- 
tain whether the removal has been properly accomplished. The advantage 


of this is illustrated in the case shown in Figures 202 and 203. Some of 
the small particles might easily have been overlooked during the operation. 
The Healing of the Jaws after Bone Operations. It is not only 
interesting and scientifically valuable to follow the healing of the bone 
after extensive operations, but it is sometimes of clinical importance. 
In the case of osteomyelitis, described on page 126-128, many small 
sequestra could be located at different periods of the healing process. 
The knowledge of their exact location facilitated their removal greatly. 
Some of the later pictures from this case are shown in Figures 304-309. 


Roentgenograms of Previously Treated Pulps 

Figures 214-222. 

Roentgen Examination: The teeth in all of these pictures show 
root canals which have been only partly filled and, in many cases, not 
properly condensed. Note also how the periapical tissues have been 


Figure 214. 

Figure 216. 

Figure 2: 


Figure 21 

l-i(;rKF. jis. 

Figure 219. 

Figure 220. 



Figure 221 


Roentgenograms of Teeth Used as Bridge Abutments 

Figures 223-227. 

Patient: Mr. W. 

History: All the bridge work shown in the illustrations had been in 
the patient's mouth only a very short time. 

Roentgen Examination: Shows radiolucent areas on many of the 
teeth indicating abscesses, which existed at the time the root canals were 
filled, or resulted from poor root canal work done later. 


Figure 223. 

Figure 224. 

Figure 22= 

Figure 226. 

Figure 227. 


Roentgenograms Showing Broken Root Canal Instruments 

Figure 228. 
The radiopaque object in the root canal of the upper first bicuspid 

was found to be a piece of a broach. 

Figure 229. 

The radiopaque object in the distal root canal of the first molar was 
found to be the point of a root canal drill. 

Figure 230. 

In the apex of the lateral incisor there is a small radiopaque object 
which appears much lighter than the root canal filling. 

Roentgenograms Showing Root Perforations 

Figure 231. 

The cuspid shows the root canal filling in the proper place, but the 
post of the porcelain crown protrudes on the side of the crown. Note 
the radiolucent area representing the lateral granuloma. 

Figure 232. 

The root of the first bicuspid has been perforated at the mesial side 
and the filling protrudes into the alveolar bone. 


Figure 228. 

Figure 229. 

Figure 230. 

Figure 231. 

Figure 23- 


Roentgenograms Used as an Aid in Root Canal Cleaning and Filling 

Figures 233-235. 

Figure 233 shows poor root canal filling. 

Figure 234 shows wire inserted to indicate the distance cleaned out. 

Figure 235 shows new filling. 

Figures 236-240. 

Figure 236 shows lower first molar. Note the change in the bone 
surrounding the apices. This, being pathological, leads to the conclusion 
that the pulp is infected. 

Figure 237 was taken with a rubber dam ligated into place and a 
broach inserted into the distal canal. 

Figure 238 shows broaches in the two canals of the mesial root, indi- 
cating that the end has almost been reached. 

Figure 239 shows three broaches inserted in the canals of the molar. 
These extend to the very ends. 

Figure 240 shows the completed root canal fillings. 


S^ ^ 

Figure 23^. Figure 234. Iiulrk 235. 

Figure 236. 

Figure 237. 

Figure 238. 



Figure 239. 

Figure 240. 


Roentgenograms as an Aid in Root Canal Filling 

Figures 241-243. 

Figure 241 shows lateral incisor and cuspid with poor root canal 

Figure 242 shows wires inserted indicating that the ends of the canals 
have been reached. 

Figure 243 shows new root canal fillings. 

Figures 244-250. 

Figure 244 shows the root canal properly filled with a small excess 
of chloropercha, which went through the apical foramen. 

Figure 245 shows a root canal filling previous to apicoectomy. Chloro- 
percha was pressed through the foramen into the granuloma. 

Figure 246 shows the root canal filling of an upper central incisor. 
Note the accessory canal and the excess of gutta percha beyond both 
apical foramina. 

Figure 247 shows the root canal filling of an upper lateral incisor. 

Figure 248 shows the corkscrew variety of root canal filling in a lower 

Figure 249 shows the filling replaced with a small excess of soft chloro- 
percha outside of the foramen. 

Figure 250 shows the root canal filling of an upper cuspid, the apex 
being very close to the antrum. 


Figure 241. 

Figure 244. Figure 245. Figure 246. Figure 24} 

Figure 248. 

Figure 249. 

Figure 250. 


Roentgenograms of Teeth not Suitable for Apicoectomy 

Figures 251-253. 

Figure 251 shows the radiolucent area extending almost to the cervical 
margin of the alveolar process. 

Figure 252 shows a very short root, entirely surrounded by a radio- 
lucent area. 

Figure 253 shows almost the entire alveolar socket involved by an 
abscess area. 

Roentgenograms Showing Apicoectomy 

Figures 254-257. 

Figure 254 shows the condition before the operation. 
Figure 255 shows wires in the root canals to indicate the extent to 
which they have been cleaned. 

Figure 256 shows the new fillings in the root canals. 

Figure 257 shows the condition after apicoectomy has been performed. 



Figure 252. 

Figure 253. 

Figure 254. Figure 255. Figure 256. Figure 257. 


Roentgenograms Showing Apicoectomy 

Figures 258-262. 

Figure 258 shows the condition before treatment. 

Figure 259 shows a wire in the cuspid. 

Figure 260 shows the root canal filling completed in the cuspid and 
second bicuspid, the first bicuspid having been extracted because the 
root canals could not be opened properly. 

Figure 261 shows the bridge cemented in place. 

Figure 262 shows the condition after apicoectomy has been performed 
on both teeth. 

Figures 263-266. 

Figure 263 shows the condition after apicoectomy has been performed 
on a lower central incisor. 

Figure 264 shows the condition after apicoectomy has been performed 
on both lower central incisors. 

Figure 265 shows the condition before apicoectomy was performed. 
Note the broken root canal instrument and the bent root of the lateral 

Figure 266 shows the condition after the operation. 



Figure 2^8. 

T ■ X 



Figure 260. 

Figure 259. 


Figure 261 

Figure 262 

Figure 263. 

Figure 264. 

Figure 26 > 

Figure 266. 


Roentgenograms Showing Healing after Apicoectomy 

Figures 267-270. 

Figure 267 shows an abscess caused by a dead pulp. 

Figure 268 shows the root canal treated and filled. 

Figure 269 shows the condition after apicoectomy was performed. 

Figure 270 shows the progress of the healing after eight months. 

Figures 271-274. 

Figure 271 shows the root canal filling and condition of periapical 
tissues before the operation. 

Figure 272 shows the condition after treatment and filling of the root 

Figure 273 shows the condition after the operation. 

Figure 274 shows new bone formation nine months after the operation. 



Figure 267. Figure 268. Figure 269. Figure 270. 



Figure 272. 

Figure 273. 

Figure 274. 


Roentgenograms Showing Healing after Apicoectomy 

Figures 275-278. 

Figure 275 shows condition immediately after apicoectomy was 
performed on the upper lateral and central incisors. 

Figure 276 shows progress of the healing after two months. 
Figure 277 shows progress of the healing after ten months. 
Figure 278 shows the bony wound entirely filled in after two years. 


Figure 275. 

Figure 276. 

Figure 277. 


Figure 278. 


Roentgenograms Showing Healing after Apicoectomy 

Figures 279-281. 

Figure 279 shows root canal filled, apparently by the old method, 
the points not having been dissolved in chloroform and resin placed 
in the canal. 

Figure 280 shows the condition after the operation. 

Figure 281 shows the bony wound entirely filled in, after fourteen 

Figures 282-286. 

Figure 282 shows a wire in the canal indicating the extent to which 
it has been cleaned out. 

Figure 283 shows the canal after the filling has been put in. 

Figure 284 shows the crown cemented into place. 

Figure 285 shows the condition two months after the operation, the 
bone having started to fill in. 

Figure 286 shows the healing of the bone cavity fourteen months 
after the operation. 



Figure 279. Figure 280. Figure 281. 

Figure 282. Figure 283. Figure 284. 




Figure 28:;. 

Figure 286. 


Roentgenograms in Prosthetic Dentistry 

Figure 287. 

Patient: Miss N. 

History: Had feeling of pressure in left upper side of jaw, the lateral incisor being 
very sore. Shortly before the Roentgen examination she had a bridge made to replace 
the missing cuspid. No Roentgenogram was taken at that time. She consulted a 
dentist, who advised removing the pulp of the lateral incisor or taking off of bridge. 

Roentgen Examination: Shows both bicuspids and the lateral incisor vital; also 
an unerupted cuspid causing pressure on the root of the lateral incisor. 

Figure 288. 
Patient: Mr. I. V. W. 

History: Complained of occasional soreness of the central incisor. 
Roentgen Examination: Shows impacted and unerupted cuspid. 

Figure 289. 
Patient: Mr. H. W. L. 

History: Pus discharge from under the bridge and slight swelling of the gums. 
Roentgen Examinatioti: Shows unerupted cuspid, which apparently has become 
infected by the abscess condition on the lateral incisor. 

Figure 290. 
Patient: Mr. H. P. H. 

Roentgen Examination: Shows a piece of root under the bridge. Note also the 
radiolucent area around the biscupid. 

Figure 291. 

Patient: Mr. C. G. C. 

History: Had all his teeth extracted in the lower jaw and a plate made. This 
caused inflammation and pus discharge from an opening in the right lower side. 

Roentgen Examination: Shows an unerupted lower third molar which had escaped 
notice, as no Roentgen pictures were taken at the time of the extraction. The radio- 
lucent area surrounding it shows the infection of the bone. 


Figure 287. 

Figure 288. 

Figure 289. 

Figure 290. 

Figure 291. 


Roentgenograms in Prosthetic Dentistry 

Figure 292. 

Patient: Mr. H. K. B. 

History: Inflammation of gum under the bridge and sinus, from 
which there was discharge of pus. 

Roentgen Examination: Shows two roots and large radiolucent areas, 
beneath the bridge. 

Figure 293. 
Patient: Mr. P. 
History: Swelling on gum. 
Roentgen Examination: Shows two infected roots under the bridge. 

Figures 294-296. 

Patient: Mr. R. S. C. 

History: Patient was hit with a hockey stick, fracturing the central 
incisor (see Figure 294), and two fragments of the tooth were removed 
(see Figure 295). By means of the Roentgen picture a dummy was 
carved with a root to fit exactly into the socket. It was attached by 
means of a staple crown to the other central incisor (see Figure 296). 




Figure 202. ' ' Figure 293. 


Figure 294. 


Figure 295. Figure 296. 


Roentgenograms in Orthodontia 

Figure 297. 

Patient: Mr. C. 

Roentgen Examination: This is a case of orthodontia. The cuspid 
was missing and its location was ascertained to find out the possibility 
of drawing it into place. 

Figures 298-301. 

Patient: Mr. F. 

History: Some of the temporary molars are still in place, with no 
sign of the permanent bicuspids coming. 

Roentgen Examination: In the upper jaw there is no evidence of 
the bicuspids and the left upper cuspid is growing in an oblique direction. 
In the lower jaw both first bicuspids are partially erupted, but the second 
bicuspids are missing. Note that the roots of the temporary molars 
have been absorbed, although the permanent teeth are absent. 


Figure 297. 


Figure 298. 

Figure 299. 

Figure 300. 

Figure 301 


Roentgenograms Showing Results of Operations 

Figures 302-303. 

Figure 302 shows a Roentgenogram of a follicular cyst containing 
many incompletely formed teeth. 

Figure 303 shows a second Roentgen picture taken after the operation, 
establishing the fact that all the particles have been removed. 


Figure 302. 

Figure 303. 


Roentgenograms Showing the Process of Healing of Bone 

Figures 304-305. 

Figure 304 shows a case of osteomyelitis of the mandible, described 
on page 126. 

Figure 305 shows a Roentgen picture taken eight months later, the 
bone having healed entirely except in one or two places. Note the 
mental foramen, which is radiolucent and a small radiopaque sequestrum 
surrounded by a radiolucent area of inflammatory granulation tissue. 


Figure 304. 


Roentgenograms Showing Healing Process of Bone 

Figures 306-307. 

Figure 306 shows a Roentgen picture of the other side in the case of 
osteomyeHtis of the mandible, reported on page 126, taken before the 

Figure 307 shows complete healing on this side after a period of ten 


Figure 306. 

Figure 307. 


Roentgenograms Showing Healing of Bone 

Figures 308-309. 

Figure 308 shows a Roentgen picture of a case of a periodontal cyst 
of the mandible described on page 140. 

Figure 309 shows a Roentgen picture taken eight months later, showing 
how the bone has grown into the cavity. 


Figure 308. 

Figure 309. 



THE important discovery that oral lesions may be the cause of various 
somatic diseases has brought about great changes in the practice of 
dentistry. The man who previously thought his only duty was mechani- 
cally to repair diseased or lost dental tissue is now impelled, if he is sin- 
cerely interested in the health of his patient and the development of his 
profession, to a deeper study of the patholog)' of the mouth. ^ 

Oral Lesions as the Primary Cause of Systemic Disease. The 
physician has for a long time realized that infections may be transported 
from foci in the nose, throat, intestinal tract and genito-urinary system. 
The lesions of the teeth and jaws are only a newly recognized etiological 
factor in cases of some systemic diseases. 

Secondary Lesions. Infectious processes of the jaws may spread and 
involve neighboring parts, causing osteomyelitis, necrosis of the jaws, 
maxillary sinusitis and periodontal cysts, which may grow to tremendous 
size and often contain a great deal of pus. Such secondary lesions may in 
turn become foci of systemic diseases. 

Discharge of Pus into the Mouth. Abscesses with sinuses, pyorrhea 
pockets and suppurating surface lesions of the mouth discharge pus and 
bacteria into the oral cavity, where it is mixed and swallowed with the 
saliva and food. Frequently such conditions cause infections of the throat 
and tonsils, as well as gastric and intestinal disorders. 

Absorption through the Lymphatic Channels. The lymphatic system 
and especially the lymph glands have the ofitice to absorb and dis- 
pose of harmful substances, such as are liberated in all inflammatory 
conditions. A certain amount of pus may, however, reach the circulation 
via the lymph system, while not infrequently we find the lymphatics or 
the glands seriously affected. Tubercular infection of the submaxillary 
lymph glands, independent of general tuberculosis, often spreads through 

1 Thoma, K. H. Oral Abscesses. 


these channels. Fifty clinical observations have been reported by Pro- 
fessor Cantani of Naples.^ 

Absorption through the Blood Channels. Haematogenous infection 
is the most important way by which the disease may be transported from 
the original focus to other parts of the body. Bacteria, or the poisons 
produced by bacterial activity, or both, may be taken up by the blood 
stream and cause various secondary disturbances. The streptococcus 
has been isolated from joints and the staphylococcus has also been experi- 
mented with and found to cause joint lesions in rabbits when injected 
intravenously. One or both of these bacteria are almost always found 
in tooth abscesses, together with a large variety of other microorganisms, 
saprophytes and anaerobes of all kinds, which split the necrosed tissue 
into complicated by-products, frequently strong protein poisons. In 
opening an abscessed tooth, such by-products can very frequently be 
recognized by the sense of smell and it would be surprising if they did 
not cause a great deal of trouble when absorbed into the system. Clinical 
evidence has of late been accumulated to prove that haematogenous 
absorption from oral lesions is frequently the obscure cause of systemic 
diseases. Toxemia due to such conditions impairs the patient's general 
health so that he is no longer able to do a full day's work, or is unable 
to withstand ordinary fatigue. If abscess conditions can be found in 
the mouths of these patients by means of Roentgen pictures, the removal 
of the lesions is usually followed promptly by a distinct improvement in 
the general health. Infectious arthritis and endocarditis are now gener- 
ally believed to be due to a blood-carried infection and there are many 
cases of the more acute type of these diseases on record where the removal 
of the focus resulted in a prompt cure or a marked improvement. 

Oral Lesions as Secondary Factors. In chronic disease, the hopeful 
therapeutic measure lies in improving the functional efficiency of the 
body and in improving the general health.^ To further this achieve- 
ment, it is important to remove all necrotic tissue, because the organs 
whose function it is to complete disease must be greatly taxed by their 
effort to eliminate the toxins and bacteria from such conditions when 

1 Cantani, Prof. Arnoldo. La Clinica Italiana. June and July, 1914. 

^ McCrudden, F. H. The Treatment of Chronic Diseases is a Problem of Applied Physiology. 
Boston Medical and Surgical Journal, Vol. clxxv, No. 2. 


they might be usmg the energy thus expended to advantage in other 

When removing foci in diseases such as chronic infections arthritis 
or subacute endocarditis we very frequently note a distinct improvement, 
which does not necessarily mean that the original focus or cause has 
been removed, but that the protective forces of the body have less to take 
care of and this results in a general improvement. 

While a perfectly healthy body may take care of a certain amount of 
toxin, the same amount may produce serious results in a patient suffering 
from subacute endocarditis. The chart in Figure 310 shows the effect 
of an infectious process occurring in a patient with such a condition. 
The result of removing a focus is shown in the chart in Figure 311. The 
patient did not derive much benefit from the treatment he received from 
July to October, but upon removal of an abscessed tooth in October he 
gained in weight from no to 130 pounds in three months' time. 

Referred Nervous Irritation. Reflex manifestations from one branch 
of the fifth nerve to another, or to communicating nerves, is quite a 
common occurrence, but often such pains are due to the most obscure 
causes. They may arise from an infectious lesion, causing inflammation 
of one of the branches of the maxillary or mandibular nerves, from pres- 
sure due to impacted and unerupted teeth, broken-off roots, ill-fitting 
fillings, crowns or bridges. Calcarious deposits in the dental pulp, 
commonly called pulp stones, are known to be another etiological factor. 
Sometimes after removing the pulp from a tooth there is continued pain 
due to an inflammatory condition or irritation of the small dental nerve, 
broken off at the apical foramen. The author has had several such 
cases which were relieved by apicoectomy. The pain may be referred 
to other organs, such as the eye and ear, or to various parts of the head 
and neck, and may be of varying degrees; that is, dull, slight and bear- 
able, or excruciating. Attacks may come at irregular intervals and 
between them the patient may be free from pain or have only a dull 
aching. Impacted teeth may lie dormant for a long time and suddenly 
start exerting pressure, this process of rest and activity being repeated 
at irregular intervals. 

Insomnia, neurasthenia, insanity and kindred nervous disorders may 
have impacted or abscessed teeth as an etiological factor. Many care- 
fully observed cases are on record which have been cured by removing 


a dental cause. Dr. Henry S. Upson in his book, "Insomnia and Nerve 
Strain," lays great stress on the importance of the teeth as an etiological 
factor of many mental disturbances. 

Examination of the Oral Cavity by the Dentist. The acute forms of 
diseases have always been more or less feared on account of their violent 
symptoms. They are, as a rule, easily diagnosed and seldom neglected. 
The mouth, however, is more frequently the seat of chronic diseases which 
may exist for a long time without even giving local symptoms. The 
patient, having no discomfort in the diseased part, is usually unaware 
of the condition and as no special complaint is made, such chronic lesions 
sometimes develop under the very eyes of the general practitioner of 
dentistry. He, as a rule, spends little time in making a thorough exami- 
nation of the mouth and adjacent parts, being too busy with his routine 
work and its many important and complicated details. It is just such 
symptomless lesions which so often cause obscure complications in neigh- 
boring parts and which are the foci of systemic infections. The Roent- 
genologist's examination reveals many unsuspected conditions in the 
mouths of patients who have had constant attention by conscientious 
dentists, and it is, therefore, to the interest of the general practitioner to 
improve his method of examination. Roentgenographic diagnosis is 
absolutely necessary to find out the condition of devitalized teeth or the 
presence of unerupted teeth and it is therefore important when examining 
a patient's mouth to use Roentgenograms as an adjunct in making a cor- 
rect diagnosis. If the dentist has not a Roentgen machine of his own, 
he can easily secure pictures of the suspected teeth from a Roentgenologist, 
who will not only take the films, but will also give expert advice as to the 
interpretation of the pictures. 

Examination of the Oral Cavity by the Physician. The physician 
often has occasion to inquire into the condition of his patient's mouth, 
especially when in search of a focus or foci of the disease concerning which 
the patient is consulting him. The mouth should not be overlooked by 
the diagnostician when making a thorough physical examination. Some 
physicians are contented with "The dentist is visited regularly," and 
"There is absolutely nothing wrong with the teeth," but the thorough 
diagnostician will not be satisfied except with a report based upon a careful 
examination and Roentgenographic diagnosis made by a dentist or special- 
ist in whose judgment he can trust. Prospective mothers and patients 


who expect to undergo serious operations should have their teeth carefully 
examined because the mouth, as the gateway to the digestive system, 
should be put in such condition that the carefully selected food will not 
be deteriorated by pus escaping from pyorrhea pockets and sinuses. 
Such examination will also assure them that their recovery will not be 
delayed nor complications invited by the presence of pus and bacteria, 
which may reach the intestinal tract with food and sali\-a or which may be 
aspired into the lungs while under the anesthetic. It is a well-known 
fact that subacute attacks of dormant, chronic, infectious lesions start 
when the body is at a low resistance, or when all the protective forces of 
the body are being used to build up during recovery. To prevent an active 
abscess or a toothache during such an important time is of great service 
to the patient and shows forethought and thoroughness on the part of the 


Charts Showing the Effect of Infection 

Figures 310-311. 

Figure 310 shows the chart of a patient with subacute endocarditis 
who had an infection the latter part of June, 1915. Note the long con- 
tinued effect this had on the pulse rate. The same result occurred after 
the patient had scarlet fever. After four months the temperature was 
still 99.5 F. and the pulse rate was very high and irregular. 

Figure 311 shows a chart of another patient with subacute endo- 
carditis. The star marks the time when a tooth abscess was removed. 
This caused a quick rise in the weight curve. 





19 lb 




Figure 310. 

? 4^iioAriiTC" c-ksnArAorkiT 

1 c 







Figure 311. 






Abrasion of teeth 

Abscess, alveolar, acute . i lo-i 1 2 

Abscess, alveolar, blind. 1 13-130 

Abscess, subacute 131-132 

Apicoectomy, healing of 

bone 267-296 

Apicoectomy, teeth 

not suitable for 251-253 

Apicoectomy cases 254-286 

Atrophy of the jaws. . . 173 

Bone healing after 

apicoectomy 267-296 

Bone healing after cyst 

operation 308-309 

Bone healing after 

osteomyelitis 304-307 


77 Decay of teeth 83-88 

97 Dentistry, prosthetic, 

99-101 cases 287-296 

103 Development of teeth, 

normal 10-16 







Endocarditis, effect of 


infection on 

Endocarditis, effect of 



removal of infection. . 



Exostosis of tooth roots 







Fractures of the jaws 





Fractures of the teeth . . 



Calculus, salivary 211-213 

Canal, normal mandil)- 

ular 29 

Carcinoma of the jaw. . 198 

Cyst, dentigerous 187-190 

Cyst, periodontal, mul- 

tilocular 192-196 

Cyst, periodontal, of 

ma.xillary sinus 195 

Cyst, periodontal, simple 191 

Cyst periodontal, simple, 

without teeth 193-194 

Cyst operation, bone 

healing after 308-309 

Granuloma, apical 113 

Granuloma, dental 113-130 99-10 

Granuloma, i n t e r r a- 

dicular 114 9< 


135-137 Granuloma, lateral. 

143 Jaws, atrophy of 173 120 

139 Jaws, carcinoma of 198 147 

Jaws, fractures of 174 123 

141 Jaws, necrosis of 184-186 131-133 

T * ^u■ c [176-179 127-129 

Jaws, osteonwclitis of . . ■! 

197 1304-307 193-195 






Jaws, ostitis of 



Result of operations. . . . 



Joint, mandibular, nor- 

Root canal cleaning and 





Root canal perforations 




Root canals previously 

Mandible, normal 







Maxilla, normal 



Root canals with 

Misinterpretation of 

broken instruments . . 










Scar bone 





Necrosis of the jaws . . . 
Necrosis of tooth roots. 

Sinus, maxillary, nor- 

Sinusitis, maxillary. . . . 






Sinusitis, maxillary, teeth 

Operations, result of . . . 



as etiological factor. . 



Orthodontia, cases. . . . 



Osteomyelitis, bone heal- 


ing after 




Teeth, decay of 



Osteomyelitis of the 

! 176-179 



Teeth, etiological factor 


i 304-307 



in maxillary sinusitis, 



Ostitis of the jaws 

Teeth, exostosis of 



Teeth, fractures of 




Teeth, misplaced 



Periodontitis, apical . . . 



Teeth, missing and 

Periodontitis, marginal 






Prosthetic dentistry, 

Teeth, necrosis of 






Teeth, normal at vary- 

Pulp canals, normal 
and abnormal 

ing ages 





Teeth, temp, retained, 

Pulp diseases 



perm, impacted 



Pulp stones 



Teeth, temp, retained, 

Pulps previously 

perm, missing 






Teeth, unerupted and 

Pyorrhea alvcolaris . . 





Teeth, used as bridge 







Radiabilily, changes 

Tuberosity, maxillary, 

produced in 








Abrasion 74 

Abscess, alveolar, acute 87 

Abscess, alveolar, chronic 87 

Abscess due to marginal periodontitis. . 107 

Abscess, subacute 89 

Absence, congenital, of temporary and 

permanent teeth S3 

Absorption through blood channels .... 200 

Absorption through lymph channels. . . 199 

Air sinuses, diseases of 148 

Apicoectomy 161 

Apicoectomy, checking up the different 

steps 161 

Apicoectomy, following up healing 161 

Apicoectomy, prognostic Roentgen ex- 
animation ... 161 

Arthritis, infectious 200 

Attack, subacute 89 


Blood channels, absorption through 200 

Bone operations, checked up by the 

Roentgen ray 163 

Bone operations, healing of the jaws 

after 162 


Calcification of permanent teeth 24 

Calcification, of temporary teeth 22 

Calculi, salivary 1 54 

Canal, mandibular 27 

Carcinoma of the jaws 118 

Caries of the teeth 74 

Case reports, index of 209 

Chronology of human dentition 25 

Conditions, pathological 12 

Conditions, pathological, Roentgeno- 

graphic study of 51 

Cysts, follicular or dentigerous 118 

Cysts, multilocular 118 

Cysts, periodontal, or radicular 118 


Decalcification of temporary teeth 23 

Dentist, oral examination by the 201 

Dentition, human, chronology of 25 

Diseases of the air sinusis 148 

Diseases of the dental pulp 86 

Diseases of the hard tooth substances. . 74 

Diseases of the jaws 116 

Diseases, somatic. Roentgen examina- 
tion in 199 

Diagnosis, Roentgen 11 


Ear, pain referred to 201 

Endocarditis 200 

Eruption, marginal periodontitis due to 106 

Eruption of permanent teeth 24 

Eruption of temporary teeth 23 

Eruption of the teeth, irregular 51 

Examination of the oral cavity by the 

dentist 201 

Examination of the oral cavity by the 

physician 202 

Exostosis of root apex 89 


Fractures of the jaws 116 

Fractures of the jaws, treatment. 162 

Fractures of the teeth 74 



Granulomata, apical 88 

Granulomata, dental 87 

Granulomata, interradicular 88 

Granulomata, lateral 88 


Healing of the jaws after operative in- 
terference 162 


Impaction, marginal periodontitis due to 106 

Index of case reports 20p 

Insanity 201 

Insomnia 201 

Interpretation of Roentgenograms 12 

Intraoral Roentgen method 14 

Introduction 11 

Irritation, nervous, referred 201 


Jaws and teeth, normal adult 25 

Jaws, carcinoma of '. 118 

Jaws, diffuse osteomyelitis of 116 

Jaws, diseases of 116 

Jaws, fractured, treatment of 162 

Jaws, fractures of 116 

Jaws, healing after operative inter- 
ference 162 

Jaws, necrosis of 118 

Jaws, normal relation of the teeth to . . . 27 

Jaws, osteoma of 118 

Jaws, osteosarcoma of 118 

Jaws, tumors of 118 

Joint, mandibular 25 


Lesions, oral, as primary cause of sys- 
temic disease 199 

Lesions, oral, as a secondary factor 200 

Lesions, oral, discharging into mouth, . 199 

Lesions, oral, secondary 199 

Lymph channels, absorption through . , . 199 

Lymph channels, infection of 199 


Mandible, the 27 

Mandibular canal 27 

Mandibular joint 27 

Maxilla, the 26 

Maxillary sinus 26 

Method, Roentgen extra-oral 14 

Method, Roentgen intra-oral 14 

Misconceptions 13 


Necrosis of the jaws 117 

Necrosis of the root apex 89 

Negatives, Roentgen 14 

Nervous irritation, referred 201 

Nomenclature, Roentgen 11 


Odontomata 74 

Oral conditions, pathological, Roentgen 

study of 21 

Oral tissues, normal, Roentgen study of 51 

Orthodontia, Roentgen ray in 161 

Osteoma 118 

Osteomyelitis of jaws, diffuse 116 

Osteosarcoma 118 

Ostitis of jaws 116 


Pain, referred 201 

Pathological conditions 12 

Pathological oral conditions, Roent- 

genographic study of 51 

Periodontal membrane, marginal, dis- 
eases of 106 

Periodontitis, acute 87 

Periodontitis, marginal 106 

Periodontitis, marginal, abscess due to, . 107 
Periodontitis, marginal, due to impaction 

and diflicult eruption 106 

Periodontitis, proliferating 87 

Physician, oral examination by 202 

Prints, Roentgen 14 

Prosthetic dentistry, Roentgen ray in , , 161 

Pulp, dental, diseases of 86 



Pulp, dental, inflammatory process of . . 86 

Pulp, dental, removal from vital teeth. 150 

Pulp, dental, stones in 86 

Pulps previously treated, Roentgen ex- 
amination of 160 


Radiability 12 

Radiolucency 12 

Radiolucent 12 

Radiopacity 12 

Radiopaque 12 

Radioparency 12 

Radioparent 12 

Ray, Roentgen 11 

Relation, the normal, of teeth and jaws 27 

Removal of foreign bodies 162 

Retention of temporary teeth 53 

Roentgen diagnosis 11 

Roentgen examination before removing 

vital pulps 159 

Roentgen examination in somatic dis- 
eases 199 

Roentgen examination of previously 

treated pulps 160 

Roentgen method extra -oral 14 

Roentgen method intra-oral 14 

Roentgen negatives 14 

Roentgen nomenclature 11 

Roentgen prints 14 

Roentgen ray 11 

Roentgen raj' as guide in cleaning and 

filling root canals 160 

Roentgen Ray in orthodontia 161 

Roentgen ray in prosthetic dentistry. . 161 

Roentgenogram 11 

Roentgenograms, examining of 13 

Roentgenograms, interpretation of 12 

Roentgenograms, to record progress of 

healing 159 

Roentgenograms as aid in treatment .... 157 

Roentgenograph 11 

Roentgenographic study of normal 

oral tissues 21 

Roentgenographic study of pathological 

oral tissues xi 




Root apex, exostosis of 

Root apex, necrosis of 

Root apex, result of abscess on the .... 
Root canals, cleaning and filling with 

Roentgen ray as guide 

Root canals, size, shape and numlxT of. 
Root canals, treatment of 


Sinuses, maxillarj' 26 

Sinusitis, maxillary 14S 

Sinusitis, maxillary, diseased teeth as 

cause 1 4S 

Study, Roentgenographic, of normal 

oral tissues 21 

Teeth, abrasion of 

Teeth, calcification of permanent 

Teeth, calcification of temporary 

Teeth, caries of 

Teeth, congenital absence of temporary 

and permanent 

Teeth, decalcification of temporary .... 

Teeth, eruption of permanent 

Teeth, eruption of temporary 

Teeth, fractures of 

Teeth, in youth and old age 

Teeth, irregular eruption of 

Teeth, misplaced 

Teeth, normal adult jaws and 

Teeth, partially erupted, impacted 

Teeth, retention of temporary 

Teeth, supernumerous 

Teeth, the development of 

Teeth and jaws, normal relation of the 
Teeth as etiological factor in sinus 


Tooth substances, diseases of the hard 


Treatment of fractured jaws 

Treatment of root canals